Individual
DESTINY CLARK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
6811 OLD CANTON RD APT 3305, RIDGELAND, MS 39157-1247
(769) 231-7366
Mailing address
4780 I 55 N STE 100 PMB 2296, JACKSON, MS 39211-5583
(601) 790-1738
Taxonomy
Speciality
Code
Description
License number
State
335E00000X
Prosthetic/Orthotic Supplier
Primary
—
MS
Other
Enumeration date
05/24/2023
Last updated
05/24/2023
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