Provider Demographics
NPI:1437335551
Name:CLARK, JENNIFER M (RN, FNP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:CLARK
Suffix:
Gender:F
Credentials:RN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 DOYLE PARK DR STE G04
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-4559
Mailing Address - Country:US
Mailing Address - Phone:707-303-8349
Mailing Address - Fax:707-303-2694
Practice Address - Street 1:500 DOYLE PARK DR STE G04
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-4559
Practice Address - Country:US
Practice Address - Phone:707-303-8349
Practice Address - Fax:707-303-2694
Is Sole Proprietor?:No
Enumeration Date:2008-01-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX740722363L00000X
CANP12069363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX193487901Medicaid
TX8Y5099OtherBCBS
TXP00622287OtherRR MEDICARE
TX8Y5099OtherBCBS