Provider Demographics
NPI:1982249926
Name:CLARK, JENNIFER RAE (CPNP-PC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:RAE
Last Name:CLARK
Suffix:
Gender:F
Credentials:CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2251 FM 646 RD W STE 155
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:TX
Mailing Address - Zip Code:77539-3256
Mailing Address - Country:US
Mailing Address - Phone:907-350-8538
Mailing Address - Fax:
Practice Address - Street 1:2800 E LEAGUE CITY PKWY APT 216
Practice Address - Street 2:
Practice Address - City:LEAGUE CITY
Practice Address - State:TX
Practice Address - Zip Code:77573-1676
Practice Address - Country:US
Practice Address - Phone:907-350-8538
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-13
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP142270363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics