Basic Information
| Provider Information | |||||||||
| NPI: | 1629203948 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | N.P.-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 249 HUSTED STATION RD | ||||||||
| Address2: | |||||||||
| City: | ELMER | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 083183806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8563580760 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1505 W SHERMAN AVE | ||||||||
| Address2: | |||||||||
| City: | VINELAND | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 083606912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8566418000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2009 | ||||||||
| LastUpdateDate: | 05/17/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 26NJ00198600 | NJ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.