Provider Demographics
NPI:1710569207
Name:CLARK, JESSE
Entity Type:Individual
Prefix:MR
First Name:JESSE
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8905 S PECOS RD STE 23C
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89074-7148
Mailing Address - Country:US
Mailing Address - Phone:888-592-7475
Mailing Address - Fax:
Practice Address - Street 1:8905 S PECOS RD STE 23C
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89074-7148
Practice Address - Country:US
Practice Address - Phone:888-592-7475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-23
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator