Provider Demographics
NPI:1164004750
Name:CLARK, JILL (RN)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:
Other - Last Name:ELDRIDGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:4216 W OKANOGAN AVE
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-2333
Mailing Address - Country:US
Mailing Address - Phone:912-227-0722
Mailing Address - Fax:
Practice Address - Street 1:4216 W OKANOGAN AVE
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-2333
Practice Address - Country:US
Practice Address - Phone:912-227-0722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-23
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60956158163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse