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General NPI Number Information
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NPI Number | 1265315154
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Entity Type | Individual
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Provider Name | JEANETTE MARIE CLARK ARNP
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Gender | Female
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Dates
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Enumeration Date | 07/28/2025
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Last Update Date | 01/29/2026
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Provider Practice Location Address
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Address Line | 12361 W BOLA DR STE 109
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City | SURPRISE
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State | AZ
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Zip | 85378-9021
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Country | US
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Telephone | 208-270-2178
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Fax |
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Provider Business Mailing Address
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Address Line | 4117 MOONSTONE DR
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City | BOZEMAN
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State | MT
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Zip | 59718-5111
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Country | US
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Telephone | 208-270-2178
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LA2200X
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Taxonomy Name | Adult Health Nurse Practitioner
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License Number | 334234
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License Number State | AZ
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