Provider Demographics
NPI:1518994078
Name:CLARK, JEAN A (RN, MS, CCRN, APRN)
Entity Type:Individual
Prefix:MS
First Name:JEAN
Middle Name:A
Last Name:CLARK
Suffix:
Gender:F
Credentials:RN, MS, CCRN, APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:NH
Mailing Address - Zip Code:03756-1000
Mailing Address - Country:US
Mailing Address - Phone:603-650-7390
Mailing Address - Fax:603-650-6346
Practice Address - Street 1:1 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03756-1000
Practice Address - Country:US
Practice Address - Phone:603-650-7390
Practice Address - Fax:603-650-6346
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2009-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH013011-23363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30340591Medicaid
VT0NP2131Medicaid
NH30340591Medicaid
NHNP2131Medicare PIN