Provider Demographics
NPI:1417951484
Name:CLARK, JACKIE LEAH (PHD)
Entity Type:Individual
Prefix:PROF
First Name:JACKIE
Middle Name:LEAH
Last Name:CLARK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5038 CREEKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:FLOWER MOUND
Mailing Address - State:TX
Mailing Address - Zip Code:75028-1913
Mailing Address - Country:US
Mailing Address - Phone:972-539-8558
Mailing Address - Fax:214-905-3022
Practice Address - Street 1:601 S TOOL DR
Practice Address - Street 2:
Practice Address - City:TOOL
Practice Address - State:TX
Practice Address - Zip Code:75143-1959
Practice Address - Country:US
Practice Address - Phone:903-432-1932
Practice Address - Fax:903-432-0520
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-08
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
231H00000X
TX90173237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Not Answered237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX66993OtherCSHCN
TX80220AMedicare ID - Type UnspecifiedGROUP 0082E