Provider Demographics
NPI:1669626669
Name:CLARK, JENNIFER MARIE (RN, NP (MSN))
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARIE
Last Name:CLARK
Suffix:
Gender:F
Credentials:RN, NP (MSN)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19601 MARINER AVE
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90503-1647
Mailing Address - Country:US
Mailing Address - Phone:310-371-0813
Mailing Address - Fax:310-673-1418
Practice Address - Street 1:19601 MARINER AVE
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-1647
Practice Address - Country:US
Practice Address - Phone:310-371-0813
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-05
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP 17909363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health