Provider Demographics
NPI:1215659792
Name:CLARK, JENNIFER M (RN)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:CLARK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4025 OVERLOOK LN
Mailing Address - Street 2:
Mailing Address - City:SUPERIOR
Mailing Address - State:WI
Mailing Address - Zip Code:54880-4044
Mailing Address - Country:US
Mailing Address - Phone:218-428-6850
Mailing Address - Fax:
Practice Address - Street 1:4025 OVERLOOK LN
Practice Address - Street 2:
Practice Address - City:SUPERIOR
Practice Address - State:WI
Practice Address - Zip Code:54880-4044
Practice Address - Country:US
Practice Address - Phone:218-428-6850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-13
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1863039163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WH0200XNursing Service ProvidersRegistered NurseHome HealthGroup - Single Specialty