Individual
MRS. SHANNON JACKIE CLARK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
12729 S OX CART TRL, VAIL, AZ 85641-9232
(512) 214-2841
(520) 750-0056
Mailing address
12729 S OX CART TRL, VAIL, AZ 85641-9232
(512) 214-2841
(520) 750-0056
Taxonomy
Speciality
Code
Description
License number
State
171W00000X
Contractor
Primary
11816
AZ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
162753
—
AZ
Enumeration date
12/21/2006
Last updated
12/26/2024
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