Healthcare Provider Details

I. General information

NPI: 1023315231
Provider Name (Legal Business Name): JENNIFER ALEXANDRIA CLARK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2011
Last Update Date: 01/11/2022
Certification Date: 01/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

99 MONTECILLO RD
SAN RAFAEL CA
94903-3308
US

IV. Provider business mailing address

20 BARNESON AVE #C
SAN MATEO CA
94402-2978
US

V. Phone/Fax

Practice location:
  • Phone: 925-229-7693
  • Fax:
Mailing address:
  • Phone: 310-266-2796
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number086522
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: