Healthcare Provider Details

I. General information

NPI: 1588092167
Provider Name (Legal Business Name): JENNIFER P CLARK PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER L PHILLIPS PA-C

II. Dates (important events)

Enumeration Date: 10/17/2013
Last Update Date: 03/06/2026
Certification Date: 03/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

429 N PARK AVE
BRECKENRIDGE CO
80424
US

IV. Provider business mailing address

PO BOX 800022
KANSAS CITY MO
64170-0022
US

V. Phone/Fax

Practice location:
  • Phone: 970-547-9200
  • Fax: 970-262-2196
Mailing address:
  • Phone: 800-953-0104
  • Fax: 303-765-6640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.0003835
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA.0003835
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA.0003835
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: