Provider Demographics
NPI:1265940340
Name:CLARK, JENNIFER ANNE (MED)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANNE
Last Name:CLARK
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 PULASKI RD
Mailing Address - Street 2:
Mailing Address - City:WHITEHOUSE STATION
Mailing Address - State:NJ
Mailing Address - Zip Code:08889-3516
Mailing Address - Country:US
Mailing Address - Phone:908-581-4765
Mailing Address - Fax:
Practice Address - Street 1:35 PULASKI RD
Practice Address - Street 2:
Practice Address - City:WHITEHOUSE STATION
Practice Address - State:NJ
Practice Address - Zip Code:08889-3516
Practice Address - Country:US
Practice Address - Phone:908-581-4765
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-11
Last Update Date:2018-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No171M00000XOther Service ProvidersCase Manager/Care Coordinator