Provider Demographics
NPI:1043321078
Name:CLARK, JEAN ANN (MSRN, FNP-C)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:ANN
Last Name:CLARK
Suffix:
Gender:F
Credentials:MSRN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 S PRESTON RD
Mailing Address - Street 2:
Mailing Address - City:PROSPER
Mailing Address - State:TX
Mailing Address - Zip Code:75078-8585
Mailing Address - Country:US
Mailing Address - Phone:972-347-6375
Mailing Address - Fax:972-347-6375
Practice Address - Street 1:201 S PRESTON RD
Practice Address - Street 2:
Practice Address - City:PROSPER
Practice Address - State:TX
Practice Address - Zip Code:75078-8585
Practice Address - Country:US
Practice Address - Phone:972-347-6375
Practice Address - Fax:972-347-6375
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX446522363LP2300X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX613433Medicare PIN