Provider Demographics
NPI:1356378673
Name:CLARK, JO ANN (APRN)
Entity type:Individual
Prefix:MRS
First Name:JO
Middle Name:ANN
Last Name:CLARK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:JO
Other - Middle Name:
Other - Last Name:MALOCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 629
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:AR
Mailing Address - Zip Code:71754
Mailing Address - Country:US
Mailing Address - Phone:870-235-3555
Mailing Address - Fax:870-562-2560
Practice Address - Street 1:104 HOSPITAL DRIVE
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:AR
Practice Address - Zip Code:71753
Practice Address - Country:US
Practice Address - Phone:870-235-3555
Practice Address - Fax:870-562-2560
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA01754363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR157033758Medicaid