Provider Demographics
NPI:1477341980
Name:CLARK, JILL (CNA)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:CLARK
Suffix:
Gender:
Credentials:CNA
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:
Other - Last Name:DEWALD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNA
Mailing Address - Street 1:6632 FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68104-4664
Mailing Address - Country:US
Mailing Address - Phone:402-594-9532
Mailing Address - Fax:
Practice Address - Street 1:319 S 17TH ST STE 726
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68102-1991
Practice Address - Country:US
Practice Address - Phone:402-204-1895
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-26
Last Update Date:2025-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide