Provider Demographics
NPI:1578644746
Name:CLARKE, JENNIFER GRACE (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:GRACE
Last Name:CLARKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 BREWSTER STREET
Mailing Address - Street 2:MEMORIAL HOSPITAL OF RHODE ISLAND
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02860
Mailing Address - Country:US
Mailing Address - Phone:401-729-3481
Mailing Address - Fax:401-729-3866
Practice Address - Street 1:111 BREWSTER STREET
Practice Address - Street 2:MEMORIAL HOSPITAL OF RHODE ISLAND
Practice Address - City:PAWTUCKET
Practice Address - State:RI
Practice Address - Zip Code:02860
Practice Address - Country:US
Practice Address - Phone:401-729-3481
Practice Address - Fax:401-729-3866
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD09743207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI7058942Medicaid
MA110087867AMedicaid
RI0070589421OtherMEDICARE PTAN