Provider Demographics
NPI:1912185927
Name:JASON H CLARK & SANDRA J CLARK
Entity Type:Organization
Organization Name:JASON H CLARK & SANDRA J CLARK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-514-5215
Mailing Address - Street 1:PO BOX 994
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-0994
Mailing Address - Country:US
Mailing Address - Phone:662-514-5215
Mailing Address - Fax:662-234-0172
Practice Address - Street 1:139 COUNTY ROAD 379
Practice Address - Street 2:
Practice Address - City:WATER VALLEY
Practice Address - State:MS
Practice Address - Zip Code:38965-3607
Practice Address - Country:US
Practice Address - Phone:662-514-5215
Practice Address - Fax:662-234-0172
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-01
Last Update Date:2008-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSMRT2279335V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09851011Medicaid
MS630000020Medicare PIN