Basic Information
Provider Information | |||||||||
NPI: | 1073505442 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CLARK | ||||||||
FirstName: | JESSICA | ||||||||
MiddleName: | J | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | FISHER | ||||||||
OtherFirstName: | JESSICA | ||||||||
OtherMiddleName: | J | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA C | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 2525 KANEVILLE RD | ||||||||
Address2: | FOX VALLEY ORTHOPAEDIC INSTITUTE | ||||||||
City: | GENEVA | ||||||||
State: | IL | ||||||||
PostalCode: | 601342578 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6305841400 | ||||||||
FaxNumber: | 6305841733 | ||||||||
Practice Location | |||||||||
Address1: | 2525 KANEVILLE RD | ||||||||
Address2: | FOX VALLEY ORTHOPAEDIC INSTITUTE | ||||||||
City: | GENEVA | ||||||||
State: | IL | ||||||||
PostalCode: | 601342578 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6305841400 | ||||||||
FaxNumber: | 6305841733 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/22/2005 | ||||||||
LastUpdateDate: | 12/30/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/30/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 001580 | IA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
No ID Information.