Provider Demographics
NPI:1326863010
Name:CLARK, JESSICA LYNN
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
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 1:1175 E 3200 N
Mailing Address - Street 2:
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-5464
Mailing Address - Country:US
Mailing Address - Phone:801-407-3000
Mailing Address - Fax:
Practice Address - Street 1:1175 E 3200 N
Practice Address - Street 2:
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043-5464
Practice Address - Country:US
Practice Address - Phone:801-407-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-19
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9149488-3102207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine