Basic Information
| Provider Information | |||||||||
| NPI: | 1861500654 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CLARKSON | ||||||||
| FirstName: | JENKINS | ||||||||
| MiddleName: | LUCAS | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 777 AVE H | ||||||||
| Address2: | POWELL VALLEY HEALTHCARE | ||||||||
| City: | POWELL | ||||||||
| State: | WY | ||||||||
| PostalCode: | 82435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077547257 | ||||||||
| FaxNumber: | 3077541226 | ||||||||
| Practice Location | |||||||||
| Address1: | 450 MOUNTAIN VIEW | ||||||||
| Address2: | POWELL VALLEY HEALTHCARE | ||||||||
| City: | POWELL | ||||||||
| State: | WY | ||||||||
| PostalCode: | 82435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077547257 | ||||||||
| FaxNumber: | 3077541226 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2006 | ||||||||
| LastUpdateDate: | 03/20/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | MD25997 | OR | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | 98-00815 | NC | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | 9432A | WY | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 8911641 | 05 | NC | MEDICAID |