Provider Demographics
NPI:1033463575
Name:CLARK, JENNIFER ISABEL
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:ISABEL
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:539 LENOX AVE APT 3A
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10037-1815
Mailing Address - Country:US
Mailing Address - Phone:718-585-0614
Mailing Address - Fax:
Practice Address - Street 1:348 E 146TH ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10451-5702
Practice Address - Country:US
Practice Address - Phone:718-585-0614
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-06
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator