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 1:12729 S OX CART TRL
Mailing Address - Street 2:
Mailing Address - City:VAIL
Mailing Address - State:AZ
Mailing Address - Zip Code:85641-9232
Mailing Address - Country:US
Mailing Address - Phone:512-214-2841
Mailing Address - Fax:520-750-0056
Practice Address - Street 1:12729 S OX CART TRL
Practice Address - Street 2:
Practice Address - City:VAIL
Practice Address - State:AZ
Practice Address - Zip Code:85641-9232
Practice Address - Country:US
Practice Address - Phone:512-214-2841
Practice Address - Fax:520-750-0056
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2024-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ11816171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ162753Medicaid