Provider Demographics
NPI:1598390635
Name:CLARK, JACQUELYN M (RN)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:M
Last Name:CLARK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 14096
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45250-0096
Mailing Address - Country:US
Mailing Address - Phone:513-766-2631
Mailing Address - Fax:
Practice Address - Street 1:1228 WALNUT ST APT 2
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45202-7135
Practice Address - Country:US
Practice Address - Phone:513-766-2631
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-09
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN450440163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine