Provider Demographics
NPI:1598118572
Name:CLARK, JENNIFER ROSE (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ROSE
Last Name:CLARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:ROSE
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3525 OLENTANGY RIVER RD STE 4330
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43214-3937
Mailing Address - Country:US
Mailing Address - Phone:614-255-6900
Mailing Address - Fax:614-255-6901
Practice Address - Street 1:3525 OLENTANGY RIVER RD STE 4330
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-3937
Practice Address - Country:US
Practice Address - Phone:614-255-6900
Practice Address - Fax:614-255-6901
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-14
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD474160207R00000X
IN11018950A207R00000X
OH35.145559207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine