Provider Demographics
NPI:1902144207
Name:CLARK, JERI LYNN (CPM, LM)
Entity Type:Individual
Prefix:MRS
First Name:JERI
Middle Name:LYNN
Last Name:CLARK
Suffix:
Gender:F
Credentials:CPM, LM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20158 FM 1253
Mailing Address - Street 2:
Mailing Address - City:LINDALE
Mailing Address - State:TX
Mailing Address - Zip Code:75771-3402
Mailing Address - Country:US
Mailing Address - Phone:903-787-9917
Mailing Address - Fax:
Practice Address - Street 1:20158 FM 1253
Practice Address - Street 2:
Practice Address - City:LINDALE
Practice Address - State:TX
Practice Address - Zip Code:75771-3402
Practice Address - Country:US
Practice Address - Phone:903-787-9917
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-21
Last Update Date:2013-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX99166176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife