Basic Information
| Provider Information | |||||||||
| NPI: | 1356810360 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | THRISHANNA | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 115 WHIPPOORWILL RD | ||||||||
| Address2: | |||||||||
| City: | BRANDON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 390476428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6016652953 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3502 W NORTHSIDE DR | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392134454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013625321 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2018 | ||||||||
| LastUpdateDate: | 11/19/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 902942 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.