Provider Demographics
NPI:1851406060
Name:CLARK, JERILLYN MARIE
Entity Type:Individual
Prefix:
First Name:JERILLYN
Middle Name:MARIE
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6441 W NORVELL BRYANT HWY
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL RIVER
Mailing Address - State:FL
Mailing Address - Zip Code:34429-9413
Mailing Address - Country:US
Mailing Address - Phone:352-795-1775
Mailing Address - Fax:352-795-6456
Practice Address - Street 1:6441 W NORVELL BRYANT HWY
Practice Address - Street 2:
Practice Address - City:CRYSTAL RIVER
Practice Address - State:FL
Practice Address - Zip Code:34429-9413
Practice Address - Country:US
Practice Address - Phone:352-795-1775
Practice Address - Fax:352-795-6456
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAS2131237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAS2131OtherHEARING AID LICENSE