Provider Demographics
NPI:1700940855
Name:CLARK, SHANNON JACKIE
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:JACKIE
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10750 S KNOLL CREST LN
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85706-9052
Mailing Address - Country:US
Mailing Address - Phone:520-574-2911
Mailing Address - Fax:520-750-0056
Practice Address - Street 1:10750 S KNOLL CREST LN
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85706-9052
Practice Address - Country:US
Practice Address - Phone:520-574-2911
Practice Address - Fax:520-750-0056
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ11816171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ162753Medicaid