Provider Demographics
NPI:1730347303
Name:CLARK, JOLYNN (ABO, NCLE)
Entity type:Individual
Prefix:MRS
First Name:JOLYNN
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:ABO, NCLE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19500 SE STARK ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97233-5757
Mailing Address - Country:US
Mailing Address - Phone:503-669-3995
Mailing Address - Fax:503-669-3956
Practice Address - Street 1:19500 SE STARK ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-5757
Practice Address - Country:US
Practice Address - Phone:503-669-3995
Practice Address - Fax:503-669-3956
Is Sole Proprietor?:No
Enumeration Date:2008-05-29
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FC0801XEye and Vision Services ProvidersTechnician/TechnologistContact Lens Fitter