Healthcare Provider Details

I. General information

NPI: 1073607800
Provider Name (Legal Business Name): JEANANN CLARK PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 09/18/2023
Certification Date: 09/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 E 68TH ST BOX 141
NEW YORK NY
10021-4870
US

IV. Provider business mailing address

525 E 68TH ST BOX 141
NEW YORK NY
10065-4885
US

V. Phone/Fax

Practice location:
  • Phone: 212-746-2059
  • Fax: 212-746-8596
Mailing address:
  • Phone: 212-746-2059
  • Fax: 212-746-8596

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number008259
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: