Individual
MR. JAYSON CLARK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
40 W DICKENS RD, LOVINGTON, NM 88260-8715
(575) 659-4874
Mailing address
40 W DICKENS RD, LOVINGTON, NM 88260-8715
(575) 659-4874
Taxonomy
Speciality
Code
Description
License number
State
172A00000X
Driver
Primary
57850
NM
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
98781804
—
NM
Enumeration date
09/29/2021
Last updated
12/29/2021
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