Provider Demographics
NPI:1306115142
Name:CLARK, JAYME MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:JAYME
Middle Name:MARIE
Last Name:CLARK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3252
Mailing Address - Street 2:
Mailing Address - City:VERNON
Mailing Address - State:CT
Mailing Address - Zip Code:06066-2152
Mailing Address - Country:US
Mailing Address - Phone:860-896-1422
Mailing Address - Fax:860-896-1425
Practice Address - Street 1:2800 TAMARACK AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:SOUTH WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06074-5539
Practice Address - Country:US
Practice Address - Phone:860-648-4480
Practice Address - Fax:860-648-2132
Is Sole Proprietor?:No
Enumeration Date:2011-12-23
Last Update Date:2012-11-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT002685363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical