Provider Demographics
NPI:1972361673
Name:JENKINS, LISA CLARK
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:CLARK
Last Name:JENKINS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 BUCK RD STE C
Mailing Address - Street 2:
Mailing Address - City:HANOVER
Mailing Address - State:NH
Mailing Address - Zip Code:03755-2715
Mailing Address - Country:US
Mailing Address - Phone:603-865-1321
Mailing Address - Fax:
Practice Address - Street 1:35 NEWPORT RD
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:NH
Practice Address - Zip Code:03257-5413
Practice Address - Country:US
Practice Address - Phone:603-276-0802
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-08
Last Update Date:2025-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH058362-23363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health