Provider Demographics
NPI:1790175990
Name:CLARK, JALITA LAUREN (LPN)
Entity Type:Individual
Prefix:
First Name:JALITA
Middle Name:LAUREN
Last Name:CLARK
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:JALITA
Other - Middle Name:LAUREN
Other - Last Name:DANIEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:127 TWELVE OAKS DR
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30241-9647
Mailing Address - Country:US
Mailing Address - Phone:912-614-8555
Mailing Address - Fax:
Practice Address - Street 1:2100 COMER AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-8725
Practice Address - Country:US
Practice Address - Phone:706-596-5583
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-27
Last Update Date:2015-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN070344164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse