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General NPI Number Information
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NPI Number | 1700940855
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Entity Type | Individual
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Provider Name | MRS. SHANNON JACKIE CLARK
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Gender | Female
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Dates
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Enumeration Date | 12/21/2006
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Last Update Date | 12/26/2024
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Provider Practice Location Address
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Address Line | 12729 S OX CART TRL
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City | VAIL
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State | AZ
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Zip | 85641-9232
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Country | US
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Telephone | 512-214-2841
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Fax | 520-750-0056
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Provider Business Mailing Address
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Address Line | 12729 S OX CART TRL
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City | VAIL
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State | AZ
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Zip | 85641-9232
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Country | US
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Telephone | 512-214-2841
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Fax | 520-750-0056
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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 | 171W00000X
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Taxonomy Name | Contractor
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License Number | 11816
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License Number State | AZ
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