Provider Demographics
NPI:1710612650
Name:CLARKE, JERRY M
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:M
Last Name:CLARKE
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 1:1946 N 13TH ST STE 427
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43604-7222
Mailing Address - Country:US
Mailing Address - Phone:567-343-7233
Mailing Address - Fax:
Practice Address - Street 1:1946 N 13TH ST STE 427
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43604-7222
Practice Address - Country:US
Practice Address - Phone:567-343-7233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-22
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator