Provider Demographics
NPI:1003506361
Name:CLARK, MADISON JADE
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:JADE
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 58
Mailing Address - Street 2:
Mailing Address - City:RED OAK
Mailing Address - State:OK
Mailing Address - Zip Code:74563-0058
Mailing Address - Country:US
Mailing Address - Phone:918-471-9014
Mailing Address - Fax:
Practice Address - Street 1:116 E MAIN ST STE B
Practice Address - Street 2:
Practice Address - City:WILBURTON
Practice Address - State:OK
Practice Address - Zip Code:74578-4230
Practice Address - Country:US
Practice Address - Phone:918-407-2662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-10
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program