Healthcare Provider Details

I. General information

NPI: 1043124035
Provider Name (Legal Business Name): BETTY JEAN CLARK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2026
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 REITEN DR
ASHLAND OR
97520-9794
US

IV. Provider business mailing address

625 REITEN DR
ASHLAND OR
97520-9794
US

V. Phone/Fax

Practice location:
  • Phone: 458-226-0844
  • Fax:
Mailing address:
  • Phone: 458-226-0844
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License Number
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: