Provider Demographics
NPI:1548986565
Name:CLARK, MARY JANE (RN, CHES)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:JANE
Last Name:CLARK
Suffix:
Gender:F
Credentials:RN, CHES
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:JANE
Other - Last Name:MAYS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 160
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:IL
Mailing Address - Zip Code:62321-0160
Mailing Address - Country:US
Mailing Address - Phone:217-357-6832
Mailing Address - Fax:217-357-6839
Practice Address - Street 1:1450 N COUNTY ROAD 2050 E
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:IL
Practice Address - Zip Code:62321-3551
Practice Address - Country:US
Practice Address - Phone:217-357-6832
Practice Address - Fax:217-357-6839
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-12
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA9468171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach