Provider Demographics
NPI:1942864582
Name:CLARK, JESSICA GRANGER
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:GRANGER
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 HIGHWAY 556
Mailing Address - Street 2:
Mailing Address - City:CHOUDRANT
Mailing Address - State:LA
Mailing Address - Zip Code:71227-9790
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1701 COMMERCE ST
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-6659
Practice Address - Country:US
Practice Address - Phone:318-224-8994
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-29
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9612225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist