Provider Demographics
NPI:1972788610
Name:CLARK, HELEN JACQUELINE (OD)
Entity Type:Individual
Prefix:
First Name:HELEN
Middle Name:JACQUELINE
Last Name:CLARK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:HELEN
Other - Middle Name:JACQUELINE
Other - Last Name:COOK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:122 TAZEWELL ST
Mailing Address - Street 2:
Mailing Address - City:PEARISBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24134-1632
Mailing Address - Country:US
Mailing Address - Phone:540-921-3921
Mailing Address - Fax:540-921-1328
Practice Address - Street 1:122 TAZEWELL ST
Practice Address - Street 2:
Practice Address - City:PEARISBURG
Practice Address - State:VA
Practice Address - Zip Code:24134
Practice Address - Country:US
Practice Address - Phone:540-921-3921
Practice Address - Fax:540-921-1328
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-31
Last Update Date:2018-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618001674152W00000X
IA002408152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist