Provider Demographics
NPI:1720063241
Name:CLEMENS, JENNIFER LYNN (DMD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:LYNN
Last Name:CLEMENS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:JENNIFER
Other - Middle Name:LYNN
Other - Last Name:MILLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:250 MIRASOL AVE SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97306-8593
Mailing Address - Country:US
Mailing Address - Phone:503-689-6050
Mailing Address - Fax:
Practice Address - Street 1:408 LANCASTER DR NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-4728
Practice Address - Country:US
Practice Address - Phone:503-362-3032
Practice Address - Fax:503-362-4647
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2008-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS036047122300000X
ORD8835122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR278461Medicaid