Provider Demographics
NPI:1790769065
Name:CLARK, JACKIE HAROLD SR (OD)
Entity Type:Individual
Prefix:DR
First Name:JACKIE
Middle Name:HAROLD
Last Name:CLARK
Suffix:SR
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1805 N 13TH ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-8256
Mailing Address - Country:US
Mailing Address - Phone:918-872-1833
Mailing Address - Fax:
Practice Address - Street 1:1805 N 13TH ST
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-8256
Practice Address - Country:US
Practice Address - Phone:918-872-1833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-01
Last Update Date:2011-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1129152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100761100AMedicaid