Basic Information
| Provider Information | |||||||||
| NPI: | 1427666486 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | JONAS | ||||||||
| MiddleName: | DEAN | ||||||||
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| Credential: | MSN RN, AGAC-NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 22155 JORDAN RUN RD | ||||||||
| Address2: | |||||||||
| City: | GUYSVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 457359594 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7405170674 | ||||||||
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| Practice Location | |||||||||
| Address1: | 400 MATTHEW ST STE 302 | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 457501656 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7405685207 | ||||||||
| FaxNumber: | 7405685297 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2020 | ||||||||
| LastUpdateDate: | 08/28/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | APRN.CNP.0027078 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.