=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033939962
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACLYN CLARK CRNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/15/2024
-----------------------------------------------------
Last Update Date | 10/16/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 600 E MARKET ST STE 303
-----------------------------------------------------
City | WEST CHESTER
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19382-2748
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-738-2690
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1925 WAID WAY
-----------------------------------------------------
City | DOYLESTOWN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18901-2215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-582-4422
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2100X
-----------------------------------------------------
Taxonomy Name | Acute Care Nurse Practitioner
-----------------------------------------------------
License Number | SP030814
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------