Healthcare Provider Details

I. General information

NPI: 1922339373
Provider Name (Legal Business Name): JILL E CLARK MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2010
Last Update Date: 01/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 E 3900 S STE 4I
SALT LAKE CITY UT
84124-1377
US

IV. Provider business mailing address

1220 E 3900 S STE 4I
SALT LAKE CITY UT
84124-1377
US

V. Phone/Fax

Practice location:
  • Phone: 801-263-1621
  • Fax: 801-263-1647
Mailing address:
  • Phone: 801-263-1621
  • Fax: 801-263-1647

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number73799221205
License Number StateUT

VIII. Authorized Official

Name: JILL E CLARK
Title or Position: PRESIDENT
Credential: MD
Phone: 801-263-1621