Provider Demographics
NPI:1336515329
Name:CLARK, JENNIFER (PTA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3669 OAKLEY LN
Mailing Address - Street 2:
Mailing Address - City:GREENCASTLE
Mailing Address - State:PA
Mailing Address - Zip Code:17225-8747
Mailing Address - Country:US
Mailing Address - Phone:978-873-4530
Mailing Address - Fax:855-232-8604
Practice Address - Street 1:1183 LUTHER DR
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-7407
Practice Address - Country:US
Practice Address - Phone:240-420-4112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-13
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA4348225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant