Provider Demographics
NPI:1952927428
Name:CLARK, JENNIFER LEE (RN-BC)
Entity Type:Individual
Prefix:PROF
First Name:JENNIFER
Middle Name:LEE
Last Name:CLARK
Suffix:
Gender:F
Credentials:RN-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:162 CHANDLER ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01609-2924
Mailing Address - Country:US
Mailing Address - Phone:774-312-2423
Mailing Address - Fax:508-755-6905
Practice Address - Street 1:12 QUEEN ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01610-2411
Practice Address - Country:US
Practice Address - Phone:774-312-2423
Practice Address - Fax:508-755-6905
Is Sole Proprietor?:No
Enumeration Date:2020-06-22
Last Update Date:2020-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2286841163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse