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General NPI Number Information
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NPI Number | 1598390635
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Entity Type | Individual
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Provider Name | JACQUELYN M CLARK RN
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Gender | Female
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Dates
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Enumeration Date | 03/09/2020
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Last Update Date | 03/09/2020
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Provider Practice Location Address
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Address Line | 1228 WALNUT ST APT 2
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City | CINCINNATI
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State | OH
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Zip | 45202-7135
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Country | US
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Telephone | 513-766-2631
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 14096
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City | CINCINNATI
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State | OH
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Zip | 45250-0096
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Country | US
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Telephone | 513-766-2631
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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 | 163WC0200X
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Taxonomy Name | Critical Care Medicine Registered Nurse
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License Number | RN450440
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License Number State | OH
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