Provider Demographics
NPI:1114910247
Name:CLARK, JENNIE S (PA C)
Entity Type:Individual
Prefix:
First Name:JENNIE
Middle Name:S
Last Name:CLARK
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 440547
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37244-0547
Mailing Address - Country:US
Mailing Address - Phone:865-670-6199
Mailing Address - Fax:865-670-6188
Practice Address - Street 1:1940 ALCOA HWY STE E260
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37920-2266
Practice Address - Country:US
Practice Address - Phone:865-305-6955
Practice Address - Fax:865-305-8238
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN1120363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q13828Medicare UPIN
TN311626179Medicare PIN