Provider Demographics
NPI:1003250663
Name:CLARK, JENATTE VIRGINIA (ARNP)
Entity Type:Individual
Prefix:
First Name:JENATTE
Middle Name:VIRGINIA
Last Name:CLARK
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4209 TIETON DR STE 102
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98908-3377
Mailing Address - Country:US
Mailing Address - Phone:509-654-9810
Mailing Address - Fax:509-966-8812
Practice Address - Street 1:4209 TIETON DR STE 102
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98908-3377
Practice Address - Country:US
Practice Address - Phone:509-654-9810
Practice Address - Fax:509-966-8812
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-24
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP 60329890363LF0000X
WAAP60329890207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily