Provider Demographics
NPI:1770326266
Name:CLARK, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
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 1:145 ARABIAN AVE W
Mailing Address - Street 2:
Mailing Address - City:SHAKOPEE
Mailing Address - State:MN
Mailing Address - Zip Code:55379-4642
Mailing Address - Country:US
Mailing Address - Phone:925-864-1720
Mailing Address - Fax:
Practice Address - Street 1:15600 36TH AVE N STE 120
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55446-3687
Practice Address - Country:US
Practice Address - Phone:763-595-0812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-13
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist