Provider Demographics
NPI:1972107704
Name:CLARK, JEREMY MICHAEL
Entity type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:MICHAEL
Last Name:CLARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:714 N 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:PADEN CITY
Mailing Address - State:WV
Mailing Address - Zip Code:26159-1614
Mailing Address - Country:US
Mailing Address - Phone:757-532-0680
Mailing Address - Fax:
Practice Address - Street 1:714 N 4TH AVE
Practice Address - Street 2:
Practice Address - City:PADEN CITY
Practice Address - State:WV
Practice Address - Zip Code:26159-1614
Practice Address - Country:US
Practice Address - Phone:757-532-0680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-23
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant