Provider Demographics
NPI:1639262579
Name:CLARK, JANE ELIZABETH (RNCS)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:ELIZABETH
Last Name:CLARK
Suffix:
Gender:F
Credentials:RNCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:675 TOWER AVE
Mailing Address - Street 2:SUITE 301
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06112-1273
Mailing Address - Country:US
Mailing Address - Phone:860-714-2750
Mailing Address - Fax:860-714-8591
Practice Address - Street 1:675 TOWER AVE
Practice Address - Street 2:SUITE 301
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06112-1273
Practice Address - Country:US
Practice Address - Phone:860-714-2750
Practice Address - Fax:860-714-8591
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2015-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001952364SP0809X
CT1952363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT890000637Medicare PIN