Healthcare Provider Details

I. General information

NPI: 1700796364
Provider Name (Legal Business Name): JANESSA MARIE CLARK RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2026
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15656 HWY 38
ELKTON OR
97436-9734
US

IV. Provider business mailing address

17523 HWY 38
ELKTON OR
97436-9745
US

V. Phone/Fax

Practice location:
  • Phone: 541-584-2115
  • Fax: 541-584-2113
Mailing address:
  • Phone: 541-554-6916
  • Fax: 541-584-2113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number201242580OR
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: