Provider Demographics
NPI:1891721601
Name:CLARK, JENNIFER S (PA-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:S
Last Name:CLARK
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:S
Other - Last Name:RAUE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4000 N BRENDAN LN
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57107-1286
Practice Address - Country:US
Practice Address - Phone:605-332-2883
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2025-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1582363A00000X
WI1648363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1648-023OtherWI STATE LICENSE