Provider Demographics
NPI:1063852143
Name:CLARK-JENKINS, DANA
Entity Type:Individual
Prefix:
First Name:DANA
Middle Name:
Last Name:CLARK-JENKINS
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 1:1603 SLIM RD
Mailing Address - Street 2:
Mailing Address - City:VALLIANT
Mailing Address - State:OK
Mailing Address - Zip Code:74764-5142
Mailing Address - Country:US
Mailing Address - Phone:580-212-7896
Mailing Address - Fax:
Practice Address - Street 1:100 N 5TH ST
Practice Address - Street 2:
Practice Address - City:HUGO
Practice Address - State:OK
Practice Address - Zip Code:74743-4005
Practice Address - Country:US
Practice Address - Phone:580-326-9475
Practice Address - Fax:580-326-9028
Is Sole Proprietor?:No
Enumeration Date:2013-07-03
Last Update Date:2014-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200111200AMedicaid