Provider Demographics
NPI:1568291912
Name:CLARK, JENNIFER FLORENCE (RN)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:FLORENCE
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 1:151 CROWELL AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-2844
Mailing Address - Country:US
Mailing Address - Phone:718-757-0558
Mailing Address - Fax:
Practice Address - Street 1:151 CROWELL AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-2844
Practice Address - Country:US
Practice Address - Phone:718-757-0558
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-01
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY543478163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool