Provider Demographics
NPI:1457606832
Name:CLARK, JESSICA ANN (AUD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ANN
Last Name:CLARK
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:EVENSTAD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3101 E STATE ST
Mailing Address - Street 2:SUITE 2108
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-6232
Mailing Address - Country:US
Mailing Address - Phone:208-385-3480
Mailing Address - Fax:208-385-3481
Practice Address - Street 1:3101 E STATE ST
Practice Address - Street 2:SUITE 2108
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6232
Practice Address - Country:US
Practice Address - Phone:208-489-4975
Practice Address - Fax:208-489-4089
Is Sole Proprietor?:No
Enumeration Date:2012-07-20
Last Update Date:2018-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDAUD-2269231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist