Provider Demographics
NPI:1649506221
Name:CLARK, JENNIFER NIKKOLE (MPT)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:NIKKOLE
Last Name:CLARK
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:MS
Other - First Name:JENNIFER
Other - Middle Name:NIKKOLE
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:223 PITTSBURGH ST
Mailing Address - Street 2:
Mailing Address - City:SAXONBURG
Mailing Address - State:PA
Mailing Address - Zip Code:16056-2217
Mailing Address - Country:US
Mailing Address - Phone:724-352-9445
Mailing Address - Fax:724-352-9061
Practice Address - Street 1:223 PITTSBURGH ST
Practice Address - Street 2:
Practice Address - City:SAXONBURG
Practice Address - State:PA
Practice Address - Zip Code:16056-2217
Practice Address - Country:US
Practice Address - Phone:724-352-9445
Practice Address - Fax:724-352-9061
Is Sole Proprietor?:No
Enumeration Date:2009-11-02
Last Update Date:2009-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT009666L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist