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General NPI Number Information
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NPI Number | 1356810360
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Entity Type | Individual
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Provider Name | THRISHANNA CLARK NP
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Gender | Female
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Dates
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Enumeration Date | 11/19/2018
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Last Update Date | 10/02/2025
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Provider Practice Location Address
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Address Line | 3502 W NORTHSIDE DR
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City | JACKSON
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State | MS
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Zip | 39213-4454
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Country | US
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Telephone | 601-362-5321
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Fax |
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Provider Business Mailing Address
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Address Line | 815 CLOVER RIDGE WAY
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City | BRANDON
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State | MS
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Zip | 39047-4410
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Country | US
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Telephone | 601-665-2953
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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 | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 0024177537
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License Number State | VA
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Taxonomy #2
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 902942
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License Number State | MS
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