Provider Demographics
NPI:1760608418
Name:CLARK, JESSICA C (PA-C)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:C
Last Name:CLARK
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 1:2905 CROUSE LN
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27215-8833
Mailing Address - Country:US
Mailing Address - Phone:336-538-2494
Mailing Address - Fax:336-538-2497
Practice Address - Street 1:2905 CROUSE LN
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27215-8833
Practice Address - Country:US
Practice Address - Phone:336-538-2494
Practice Address - Fax:336-538-2497
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2010-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA052894363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical