Provider Demographics
NPI:1063138949
Name:CLARK, JESSICA N (ACNP-AG)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:N
Last Name:CLARK
Suffix:
Gender:F
Credentials:ACNP-AG
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:N
Other - Last Name:MAYS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1701 LACEY ST
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-5230
Mailing Address - Country:US
Mailing Address - Phone:573-334-6431
Mailing Address - Fax:573-986-5984
Practice Address - Street 1:1701 LACEY ST
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-5230
Practice Address - Country:US
Practice Address - Phone:573-331-6431
Practice Address - Fax:573-986-5984
Is Sole Proprietor?:No
Enumeration Date:2022-10-13
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016011887363LG0600X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology