1417951484 NPI number — PROF. JACKIE LEAH CLARK PHD

Table of content: PROF. JACKIE LEAH CLARK PHD (NPI 1417951484)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417951484 NPI number — PROF. JACKIE LEAH CLARK PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARK
Provider First Name:
JACKIE
Provider Middle Name:
LEAH
Provider Name Prefix Text:
PROF.
Provider Name Suffix Text:
Provider Credential Text:
PHD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417951484
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/28/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5038 CREEKWOOD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLOWER MOUND
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75028-1913
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-539-8558
Provider Business Mailing Address Fax Number:
214-905-3022

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
601 S TOOL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TOOL
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75143-1959
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-432-1932
Provider Business Practice Location Address Fax Number:
903-432-0520
Provider Enumeration Date:
06/08/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 231H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 66993 . This is a "CSHCN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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