Provider Demographics
NPI:1679826796
Name:CLARK, JESSALYNN (APRN)
Entity Type:Individual
Prefix:
First Name:JESSALYNN
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1720 NICHOLASVILLE RD
Mailing Address - Street 2:SUITE 506
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-1404
Mailing Address - Country:US
Mailing Address - Phone:859-260-2224
Mailing Address - Fax:859-260-6375
Practice Address - Street 1:1720 NICHOLASVILLE RD
Practice Address - Street 2:SUITE 506
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-1404
Practice Address - Country:US
Practice Address - Phone:859-260-2224
Practice Address - Fax:859-260-6375
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-26
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY3007684363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY3007684OtherSTATE LICENSE