1922339373 NPI number — JILL E CLARK MD PC

Table of content: (NPI 1922339373)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922339373 NPI number — JILL E CLARK MD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JILL E CLARK MD PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1922339373
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/26/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1220 E 3900 S
Provider Second Line Business Mailing Address:
STE 4I
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84124-1377
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-263-1621
Provider Business Mailing Address Fax Number:
801-263-1647

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1220 E 3900 S
Provider Second Line Business Practice Location Address:
STE 4I
Provider Business Practice Location Address City Name:
SALT LAKE CITY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84124-1377
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-263-1621
Provider Business Practice Location Address Fax Number:
801-263-1647
Provider Enumeration Date:
01/26/2010

Additional Information

Authorized Official

Authorized Official Last Name:
CLARK
Authorized Official First Name:
JILL
Authorized Official Middle Name:
E
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
801-263-1621

Provider Taxonomy Codes

  • Taxonomy code: 208C00000X , with the licence number:  73799221205 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 10281976 . This is a "OWNERS DOB" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com