Provider Demographics
NPI:1851707194
Name:CLARK, JENNIFER SARA (PT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:SARA
Last Name:CLARK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:SARA
Other - Last Name:SIEGEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:797 EVERGREEN DR
Mailing Address - Street 2:
Mailing Address - City:WEST HEMPSTEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11552-3406
Mailing Address - Country:US
Mailing Address - Phone:516-286-4654
Mailing Address - Fax:
Practice Address - Street 1:797 EVERGREEN DR
Practice Address - Street 2:
Practice Address - City:WEST HEMPSTEAD
Practice Address - State:NY
Practice Address - Zip Code:11552-3406
Practice Address - Country:US
Practice Address - Phone:516-286-4654
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-08
Last Update Date:2018-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY036614-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist