Provider Demographics
NPI:1912498338
Name:CLARK, JEREMY JAMES
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:JAMES
Last Name:CLARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20378 STATE ROUTE 18
Mailing Address - Street 2:
Mailing Address - City:CUSTAR
Mailing Address - State:OH
Mailing Address - Zip Code:43511-9760
Mailing Address - Country:US
Mailing Address - Phone:419-889-1364
Mailing Address - Fax:
Practice Address - Street 1:1900 S MAIN ST
Practice Address - Street 2:
Practice Address - City:FINDLAY
Practice Address - State:OH
Practice Address - Zip Code:45840
Practice Address - Country:US
Practice Address - Phone:419-423-4500
Practice Address - Fax:419-423-5358
Is Sole Proprietor?:No
Enumeration Date:2018-05-21
Last Update Date:2018-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.022794363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily