Healthcare Provider Details

I. General information

NPI: 1942792684
Provider Name (Legal Business Name): JESSICA AMAKA CLARKE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2018
Last Update Date: 05/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 EAST COY SMITH HWY
MT. VERNON AL
36560
US

IV. Provider business mailing address

251 N BAYOU ST
MOBILE AL
36603-5827
US

V. Phone/Fax

Practice location:
  • Phone: 251-829-9884
  • Fax:
Mailing address:
  • Phone: 251-690-8858
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1-123212
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: