Healthcare Provider Details

I. General information

NPI: 1417563206
Provider Name (Legal Business Name): JORDAN CLARK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2020
Last Update Date: 09/17/2020
Certification Date: 09/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2312 DURWOOD RD
LITTLE ROCK AR
72207-3431
US

IV. Provider business mailing address

80 ZIRCON DR
MAUMELLE AR
72113-6049
US

V. Phone/Fax

Practice location:
  • Phone: 501-313-5973
  • Fax: 501-747-1811
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: