Provider Demographics
NPI:1972976793
Name:CLARK, JENNIFER M (RDH)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:M
Last Name:CLARK
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4915 WASHINGTON AVE STE B
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53406-4221
Mailing Address - Country:US
Mailing Address - Phone:262-619-1949
Mailing Address - Fax:877-335-3684
Practice Address - Street 1:4915 WASHINGTON AVE STE B
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53406-4221
Practice Address - Country:US
Practice Address - Phone:262-619-1949
Practice Address - Fax:877-335-3684
Is Sole Proprietor?:No
Enumeration Date:2015-11-02
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11479-16124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist