Provider Demographics
NPI:1922344381
Name:THEROS-CLARKE, JENNIFER (HIS)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:THEROS-CLARKE
Suffix:
Gender:F
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1180 BOULEVARD ST, SUITE C
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29115
Mailing Address - Country:US
Mailing Address - Phone:803-531-6403
Mailing Address - Fax:
Practice Address - Street 1:1180 BOULEVARD ST, SUITE C
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29115
Practice Address - Country:US
Practice Address - Phone:803-531-6403
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-12
Last Update Date:2019-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCHAS-0506237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist