Provider Demographics
NPI:1275248445
Name:CLARKSTON, JAMIE TIFFANY MARIE
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:TIFFANY MARIE
Last Name:CLARKSTON
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 1:16065 STATE ROUTE 772
Mailing Address - Street 2:
Mailing Address - City:PIKETON
Mailing Address - State:OH
Mailing Address - Zip Code:45661-9725
Mailing Address - Country:US
Mailing Address - Phone:740-222-9648
Mailing Address - Fax:
Practice Address - Street 1:16065 STATE ROUTE 772
Practice Address - Street 2:
Practice Address - City:PIKETON
Practice Address - State:OH
Practice Address - Zip Code:45661-9725
Practice Address - Country:US
Practice Address - Phone:740-222-9648
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-20
Last Update Date:2023-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant