Provider Demographics
NPI:1962562801
Name:CLEMENTE-METZ, JENNIFER C (PA-C, MS)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:C
Last Name:CLEMENTE-METZ
Suffix:
Gender:F
Credentials:PA-C, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 MARKET ST STE 101
Mailing Address - Street 2:
Mailing Address - City:CHARLESTOWN
Mailing Address - State:IN
Mailing Address - Zip Code:47111-9535
Mailing Address - Country:US
Mailing Address - Phone:812-503-5100
Mailing Address - Fax:770-573-9513
Practice Address - Street 1:1802 E 10TH ST
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-6016
Practice Address - Country:US
Practice Address - Phone:812-288-2488
Practice Address - Fax:770-573-9513
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000891A207RA0401X
KYPA745363A00000X
IN10000891AB363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYPA745OtherSTATE LICENSE
IN10000891AOtherSTATE LICENSE
IN300006743Medicaid
ININ3604007OtherMEDICARE INDIANA