Healthcare Provider Details

I. General information

NPI: 1669394417
Provider Name (Legal Business Name): JACKIA CLARK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2026
Last Update Date: 07/25/2026
Certification Date: 07/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 STANLEY ST
HENDERSON NC
27536-3059
US

IV. Provider business mailing address

805 STANLEY ST
HENDERSON NC
27536-3059
US

V. Phone/Fax

Practice location:
  • Phone: 984-353-8294
  • Fax:
Mailing address:
  • Phone: 984-353-8294
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: