Basic Information
Provider Information | |||||||||
NPI: | 1417951484 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CLARK | ||||||||
FirstName: | JACKIE | ||||||||
MiddleName: | LEAH | ||||||||
NamePrefix: | PROF. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PHD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5038 CREEKWOOD DR | ||||||||
Address2: |   | ||||||||
City: | FLOWER MOUND | ||||||||
State: | TX | ||||||||
PostalCode: | 750281913 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9725398558 | ||||||||
FaxNumber: | 2149053022 | ||||||||
Practice Location | |||||||||
Address1: | 601 S TOOL DR | ||||||||
Address2: |   | ||||||||
City: | TOOL | ||||||||
State: | TX | ||||||||
PostalCode: | 751431959 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9034321932 | ||||||||
FaxNumber: | 9034320520 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/08/2005 | ||||||||
LastUpdateDate: | 10/28/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/28/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X |   |   | Y |   | Speech, Language and Hearing Service Providers | Audiologist |   |
ID Information
ID | Type | State | Issuer | Description | 66993 | 01 | TX | CSHCN | OTHER |