Healthcare Provider Details

I. General information

NPI: 1659671089
Provider Name (Legal Business Name): JENNIFER RUTH CLARKE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2010
Last Update Date: 11/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5120 BEATLINE RD STE A
LONG BEACH MS
39560-3815
US

IV. Provider business mailing address

5 CHLOE CT
LONG BEACH MS
39560-5351
US

V. Phone/Fax

Practice location:
  • Phone: 228-868-4287
  • Fax: 228-868-4293
Mailing address:
  • Phone: 228-806-4181
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR855220
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: