Provider Demographics
NPI:1720594955
Name:CLARK, JACQUELINE (RN)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:
Other - Last Name:FOOTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15536 GUINN LN
Mailing Address - Street 2:
Mailing Address - City:CULPEPER
Mailing Address - State:VA
Mailing Address - Zip Code:22701-4639
Mailing Address - Country:US
Mailing Address - Phone:540-755-0350
Mailing Address - Fax:540-755-0351
Practice Address - Street 1:15536 GUINN LN
Practice Address - Street 2:
Practice Address - City:CULPEPER
Practice Address - State:VA
Practice Address - Zip Code:22701-4639
Practice Address - Country:US
Practice Address - Phone:540-755-0350
Practice Address - Fax:540-755-0351
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-26
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VARN.1664774163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse