Provider Demographics
NPI:1639958200
Name:CLARK, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:CLARK
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 1:11 TERRON CT
Mailing Address - Street 2:
Mailing Address - City:PARKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21234-5929
Mailing Address - Country:US
Mailing Address - Phone:443-704-6984
Mailing Address - Fax:
Practice Address - Street 1:11 TERRON CT
Practice Address - Street 2:
Practice Address - City:PARKVILLE
Practice Address - State:MD
Practice Address - Zip Code:21234-5929
Practice Address - Country:US
Practice Address - Phone:443-704-6984
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-25
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD8838124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist