=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356056832
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER CLARK PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2023
-----------------------------------------------------
Last Update Date | 01/18/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3600 HOUMA BLVD
-----------------------------------------------------
City | METAIRIE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70006-4230
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 504-233-0931
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 525 TUCKER AVE
-----------------------------------------------------
City | JEFFERSON
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70121-1537
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 504-330-9382
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------