Clark, Jackie Harold
Clark, Jackie Harold is an sole proprietor health care provider with primary practice located at 1805 N 13Th St , Broken Arrow OK 74012-8256. He recently has only one registered license in Eye and Vision Services Providers / Optometrist, which is considered as his primary health care specialty. Clark, Jackie Harold can be contacted via phone (918) 872-1833.Contact Information
Primary practice address
1805 N 13Th St
Broken Arrow OK 74012-8256
Phone: (918) 872-1833
Fax:
Website:
Health care specialties
| Specialty | Code | License # | State |
|---|---|---|---|
| Eye and Vision Services Providers / Optometrist | 152W00000X | 1129 | Oklahoma |
Profile Details
| NPI number | 1790769065 |
|---|---|
| LBN Legal business name | Clark, Jackie Harold |
| Credentials | Doctor of Optometry (OD) |
| Entity | Individual |
| Sole proprietor 1 | Yes |
| Enumeration date | Dec 1st, 2005 |
| Last updated | Jun 10th, 2011 - about 13 years ago |
1 A sole proprietor/sole proprietorship is an individual, and in that capacity, is qualified for a solitary NPI number. The sole proprietor have to apply for the NPI number using his or her own particular Social Security Number (SSN), instead of Employer Identification Number (EIN) regardless of whether he/she has an EIN.
Identifiers
| State | Type | Number | Issuer |
|---|---|---|---|
| All States | NPI | 1790769065 | NPPES |
| Oklahoma | MEDICAID | 100761100A |
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