Provider Demographics
NPI:1114240348
Name:CLARK RUHF, JACQUELINE MARIE (IDMT)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:MARIE
Last Name:CLARK RUHF
Suffix:
Gender:F
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 PICKET PL
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45433-1325
Mailing Address - Country:US
Mailing Address - Phone:937-271-4711
Mailing Address - Fax:
Practice Address - Street 1:4881 SUGAR MAPLE DR
Practice Address - Street 2:
Practice Address - City:WPAFB
Practice Address - State:OH
Practice Address - Zip Code:45433-5546
Practice Address - Country:US
Practice Address - Phone:937-257-9519
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-02
Last Update Date:2010-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians