Provider Demographics
NPI:1609853563
Name:CLARK, JENNIFER (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:
Last Name:CLARK
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 1:100 GRAND ST
Mailing Address - Street 2:
Mailing Address - City:NEW BRITAIN
Mailing Address - State:CT
Mailing Address - Zip Code:06052-2016
Mailing Address - Country:US
Mailing Address - Phone:860-224-5510
Mailing Address - Fax:860-224-5950
Practice Address - Street 1:100 GRAND ST
Practice Address - Street 2:ONDREA CHASSE, MEDICAL STAFF OFFICE
Practice Address - City:NEW BRITAIN
Practice Address - State:CT
Practice Address - Zip Code:06052-2016
Practice Address - Country:US
Practice Address - Phone:860-224-5305
Practice Address - Fax:860-224-5950
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2015-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT032904207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTF43854Medicare UPIN