Provider Demographics
NPI:1912614140
Name:CLARK, JENNIFER ALICIA-BECKER (MS, RD)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:ALICIA-BECKER
Last Name:CLARK
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3091 CRABTREE DR
Mailing Address - Street 2:
Mailing Address - City:TECUMSEH
Mailing Address - State:MI
Mailing Address - Zip Code:49286-7764
Mailing Address - Country:US
Mailing Address - Phone:517-605-8311
Mailing Address - Fax:
Practice Address - Street 1:4328 PAGE AVE
Practice Address - Street 2:
Practice Address - City:MICHIGAN CENTER
Practice Address - State:MI
Practice Address - Zip Code:49254-1077
Practice Address - Country:US
Practice Address - Phone:517-764-3609
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-27
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered