Provider Demographics
NPI:1760065767
Name:CLINTON, JADE (PA-C)
Entity Type:Individual
Prefix:
First Name:JADE
Middle Name:
Last Name:CLINTON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5477 GLEN LAKES DR STE 100
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-4381
Mailing Address - Country:US
Mailing Address - Phone:844-409-4657
Mailing Address - Fax:
Practice Address - Street 1:5477 GLEN LAKES DR STE 100
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-4381
Practice Address - Country:US
Practice Address - Phone:844-409-4657
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-28
Last Update Date:2024-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA14322363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty