Provider Demographics
NPI:1043721129
Name:CLARK, JESSE KAY (PA)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:KAY
Last Name:CLARK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:11001 EXECUTIVE CENTER DR STE 200
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-4393
Mailing Address - Country:US
Mailing Address - Phone:501-812-7800
Mailing Address - Fax:501-812-7777
Practice Address - Street 1:3050 TWIN RIVERS DR
Practice Address - Street 2:
Practice Address - City:ARKADELPHIA
Practice Address - State:AR
Practice Address - Zip Code:71923-4218
Practice Address - Country:US
Practice Address - Phone:501-851-7402
Practice Address - Fax:501-851-4753
Is Sole Proprietor?:No
Enumeration Date:2017-10-17
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXPA11698363AS0400X
ARPA-1067363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical