Provider Demographics
NPI:1538920343
Name:CLARK-JEFFERSON, NICOLE D
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:D
Last Name:CLARK-JEFFERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9077 JEFFERSON DR
Mailing Address - Street 2:
Mailing Address - City:NORTHFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44067-1202
Mailing Address - Country:US
Mailing Address - Phone:330-880-9801
Mailing Address - Fax:
Practice Address - Street 1:9077 JEFFERSON DR
Practice Address - Street 2:
Practice Address - City:NORTHFIELD
Practice Address - State:OH
Practice Address - Zip Code:44067-1202
Practice Address - Country:US
Practice Address - Phone:330-880-9801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-18
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle