Basic Information
| Provider Information | |||||||||
| NPI: | 1801151113 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1700 S PARK ST | ||||||||
| Address2: | |||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490012779 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693420003 | ||||||||
| FaxNumber: | 2693424284 | ||||||||
| Practice Location | |||||||||
| Address1: | 27604 MIDDLEBELT RD | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483345001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2486150652 | ||||||||
| FaxNumber: | 2486151297 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2012 | ||||||||
| LastUpdateDate: | 12/01/2014 | ||||||||
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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 | 152W00000X | 6115 | OH | N | Eye and Vision Services Providers | Optometrist | 152W00000X | 4901004816 | MI | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 1801151113 | 05 | MI | MEDICAID |