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General NPI Number Information
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NPI Number | 1457914160
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Entity Type | Individual
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Provider Name | JESSICA MARION CLARK PMHNP
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Gender | Female
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Dates
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Enumeration Date | 04/18/2019
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Last Update Date | 01/05/2022
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Provider Practice Location Address
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Address Line | 2265 COMO AVE
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City | SAINT PAUL
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State | MN
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Zip | 55108-1737
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Country | US
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Telephone | 866-821-0821
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Fax |
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Provider Business Mailing Address
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Address Line | 2265 COMO AVE
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City | SAINT PAUL
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State | MN
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Zip | 55108-1737
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Country | US
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Telephone | 651-645-5323
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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 | 6747
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License Number State | MN
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