Healthcare Provider Details

I. General information

NPI: 1972361673
Provider Name (Legal Business Name): LISA CLARK JENKINS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2024
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

88 SPLITROCK RD
GRANTHAM NH
03753-3250
US

IV. Provider business mailing address

221 MAIN ST # 4313
NASHUA NH
03060-2913
US

V. Phone/Fax

Practice location:
  • Phone: 802-252-3005
  • Fax: 603-676-0015
Mailing address:
  • Phone: 802-252-3005
  • Fax: 802-676-0015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number058362-23
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: