Provider Demographics
NPI:1841888328
Name:CLARK, JACKIE TERESA
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:TERESA
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 1:2184 ROBERTS JOURNEY
Mailing Address - Street 2:
Mailing Address - City:RAVENNA
Mailing Address - State:OH
Mailing Address - Zip Code:44266-7810
Mailing Address - Country:US
Mailing Address - Phone:330-937-5142
Mailing Address - Fax:
Practice Address - Street 1:2184 ROBERTS JOURNEY
Practice Address - Street 2:
Practice Address - City:RAVENNA
Practice Address - State:OH
Practice Address - Zip Code:44266-7810
Practice Address - Country:US
Practice Address - Phone:330-937-5142
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-09
Last Update Date:2021-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker