Healthcare Provider Details

I. General information

NPI: 1790732600
Provider Name (Legal Business Name): AMY S JURACEK CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMY S WITT CNP

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 10/25/2022
Certification Date: 10/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

809 JACKSON ST
BURKE SD
57523-2065
US

IV. Provider business mailing address

814 JACKSON ST
BURKE SD
57523-0358
US

V. Phone/Fax

Practice location:
  • Phone: 605-775-2631
  • Fax:
Mailing address:
  • Phone: 605-775-2631
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCP000467
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: