Basic Information
| Provider Information | |||||||||
| NPI: | 1588641385 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JURRENS | ||||||||
| FirstName: | TRACI | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3755 | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681030755 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023542100 | ||||||||
| FaxNumber: | 4023546171 | ||||||||
| Practice Location | |||||||||
| Address1: | 1120 N 103RD PLZ | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681141114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023915055 | ||||||||
| FaxNumber: | 4023844202 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2005 | ||||||||
| LastUpdateDate: | 06/12/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 22554 | NE | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 100264481-00 | 05 | NE | MEDICAID | 1588641385 | 05 | IA | MEDICAID |