Provider Demographics
NPI:1639418486
Name:CLARK, JAMES M (CFNP)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:M
Last Name:CLARK
Suffix:
Gender:M
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4402
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39047-4402
Mailing Address - Country:US
Mailing Address - Phone:601-992-9898
Mailing Address - Fax:601-398-0256
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-6525
Practice Address - Fax:601-984-5151
Is Sole Proprietor?:No
Enumeration Date:2013-02-13
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR854948363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07876712Medicaid
MS200329YJ5DMedicare PIN