Provider Demographics
NPI:1467503334
Name:CLARK, JACQUELYN IRENE (LPN)
Entity type:Individual
Prefix:MRS
First Name:JACQUELYN
Middle Name:IRENE
Last Name:CLARK
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48696 BENWOOD RD
Mailing Address - Street 2:
Mailing Address - City:SARDIS
Mailing Address - State:OH
Mailing Address - Zip Code:43946-9638
Mailing Address - Country:US
Mailing Address - Phone:740-483-2249
Mailing Address - Fax:
Practice Address - Street 1:48696 BENWOOD RD
Practice Address - Street 2:
Practice Address - City:SARDIS
Practice Address - State:OH
Practice Address - Zip Code:43946-9638
Practice Address - Country:US
Practice Address - Phone:740-483-2249
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN091690164W00000X
WV12185164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2564130Medicaid