Provider Demographics
NPI:1801151113
Name:CLARK, JESSICA A (OD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:A
Last Name:CLARK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 S PARK ST
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49001-2779
Mailing Address - Country:US
Mailing Address - Phone:269-342-0003
Mailing Address - Fax:269-342-4284
Practice Address - Street 1:27604 MIDDLEBELT RD
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-5001
Practice Address - Country:US
Practice Address - Phone:248-615-0652
Practice Address - Fax:248-615-1297
Is Sole Proprietor?:No
Enumeration Date:2012-07-12
Last Update Date:2014-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6115152W00000X
MI4901004816152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1801151113Medicaid
MI0C97655Medicare PIN
MI1801151113Medicaid
MIMI1772Medicare PIN