Provider Demographics
NPI:1043348634
Name:CLARK, JODI L
Entity Type:Individual
Prefix:MRS
First Name:JODI
Middle Name:L
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 1:90 METCALF DR
Mailing Address - Street 2:
Mailing Address - City:ERIN
Mailing Address - State:TN
Mailing Address - Zip Code:37061-5010
Mailing Address - Country:US
Mailing Address - Phone:931-289-4808
Mailing Address - Fax:
Practice Address - Street 1:1330 N MAIN ST
Practice Address - Street 2:
Practice Address - City:TENNESSEE RIDGE
Practice Address - State:TN
Practice Address - Zip Code:37178-4003
Practice Address - Country:US
Practice Address - Phone:931-721-3312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider