Provider Demographics
NPI:1316136500
Name:JURICH, JACK
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:
Last Name:JURICH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 BRAEBURN RD
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06107-1605
Mailing Address - Country:US
Mailing Address - Phone:212-255-6632
Mailing Address - Fax:
Practice Address - Street 1:15 BRAEBURN RD
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06107-1605
Practice Address - Country:US
Practice Address - Phone:212-255-6632
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-24
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014799103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02161493Medicaid
NY02161493Medicaid