Provider Demographics
NPI:1740449719
Name:CLARK, JESSICA LYNN (MD)
Entity type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:LYNN
Last Name:CLARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:600 GRAND PANAMA BLVD STE 104
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32407-3459
Mailing Address - Country:US
Mailing Address - Phone:850-238-8511
Mailing Address - Fax:850-654-3320
Practice Address - Street 1:600 GRAND PANAMA BLVD STE 104
Practice Address - Street 2:
Practice Address - City:PANAMA CITY BEACH
Practice Address - State:FL
Practice Address - Zip Code:32407-3459
Practice Address - Country:US
Practice Address - Phone:850-238-8511
Practice Address - Fax:850-238-8873
Is Sole Proprietor?:No
Enumeration Date:2008-06-05
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME127249207N00000X
TXN3566207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology