Provider Demographics
NPI:1851564348
Name:CLARK, JAMIE
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:
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 1:211 GIBSON ST NW
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-2115
Mailing Address - Country:US
Mailing Address - Phone:703-737-7707
Mailing Address - Fax:
Practice Address - Street 1:211 GIBSON ST NW
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176-2115
Practice Address - Country:US
Practice Address - Phone:703-737-7707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-07
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2201001128231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist