Provider Demographics
NPI:1699847921
Name:CLARK-BRUNING, JENNIFER R (PAC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:R
Last Name:CLARK-BRUNING
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 ASHWOOD CT
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27455-3005
Mailing Address - Country:US
Mailing Address - Phone:336-282-1414
Mailing Address - Fax:336-282-1515
Practice Address - Street 1:1900 ASHWOOD CT
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27455-3005
Practice Address - Country:US
Practice Address - Phone:336-282-1414
Practice Address - Fax:336-282-1515
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2015-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102670363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical