Provider Demographics
NPI:1245567247
Name:CLARK, JENNIFER SELLECK (FNP-C)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:SELLECK
Last Name:CLARK
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1840 MARTIN LUTHER KING JR BLVD STE C4
Mailing Address - Street 2:
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27514-7415
Mailing Address - Country:US
Mailing Address - Phone:919-510-6679
Mailing Address - Fax:
Practice Address - Street 1:1840 MARTIN LUTHER KING JR BLVD STE C4
Practice Address - Street 2:
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27514
Practice Address - Country:US
Practice Address - Phone:919-510-6679
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-11
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5004547363LF0000X
NC206302363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1245567247Medicaid