Provider Demographics
NPI:1770035966
Name:CLARK, TERRI JO (NP)
Entity Type:Individual
Prefix:
First Name:TERRI
Middle Name:JO
Last Name:CLARK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:288 COUNTRY LANE DR
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:TX
Mailing Address - Zip Code:77657-6804
Mailing Address - Country:US
Mailing Address - Phone:409-813-1677
Mailing Address - Fax:409-813-2710
Practice Address - Street 1:2353 N MAIN ST
Practice Address - Street 2:
Practice Address - City:VIDOR
Practice Address - State:TX
Practice Address - Zip Code:77662-2610
Practice Address - Country:US
Practice Address - Phone:409-813-1677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-04
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP132041363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily