Provider Demographics
NPI:1740773290
Name:CLINTON, JEFFREY MARK (NP-C)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:MARK
Last Name:CLINTON
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2026 CHARLOTTE
Mailing Address - Street 2:
Mailing Address - City:TEMPERANCE
Mailing Address - State:MI
Mailing Address - Zip Code:48182-1570
Mailing Address - Country:US
Mailing Address - Phone:419-467-4646
Mailing Address - Fax:
Practice Address - Street 1:818 RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-1446
Practice Address - Country:US
Practice Address - Phone:517-265-0230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-10
Last Update Date:2018-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704241472NSA18486363LF0000X
OHAPRN.CNP.022675363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily