Provider Demographics
NPI:1396107553
Name:CLARK, JAZEMINE
Entity type:Individual
Prefix:MRS
First Name:JAZEMINE
Middle Name:
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 1:458 WEST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:PLAIN CITY
Mailing Address - State:OH
Mailing Address - Zip Code:43064
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:458 W MAIN ST
Practice Address - Street 2:
Practice Address - City:PLAIN CITY
Practice Address - State:OH
Practice Address - Zip Code:43064-1035
Practice Address - Country:US
Practice Address - Phone:614-849-2981
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-25
Last Update Date:2016-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator