MEDICARE: JAIME N CLARK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	148498	OH

General Provider Information

NPI Number	:	1396080388
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAIME N CLARK

Provider Business Mailing Address
First Line	:	2812 MICHAM RD
Second Line	:
City	:	TOLEDO
State	:	OH
Zip	:	43615-1953
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2812 MICHAM RD
Second Line	:
City	:	TOLEDO
State	:	OH
Zip	:	43615-1953
Country	:	US
Telephone Number	:	567-322-4141
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/03/2012
Last Update Date	:	12/03/2012

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