Healthcare Provider Details

I. General information

NPI: 1043671696
Provider Name (Legal Business Name): NIKKI J CLARK FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NIKKI C JESSUP FNP-BC

II. Dates (important events)

Enumeration Date: 03/10/2016
Last Update Date: 03/04/2026
Certification Date: 03/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3520 NW CENTRE DR
LAKE WORTH TX
76135-3612
US

IV. Provider business mailing address

3520 NW CENTRE DR
LAKE WORTH TX
76135-3612
US

V. Phone/Fax

Practice location:
  • Phone: 701-364-4999
  • Fax:
Mailing address:
  • Phone: 701-364-4999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1180324
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number893588
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number893588
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: