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General NPI Number Information
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NPI Number | 1609853563
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Entity Type | Individual
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Provider Name | JENNIFER CLARK MD
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Gender | Female
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Dates
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Enumeration Date | 12/30/2005
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Last Update Date | 04/29/2015
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Provider Practice Location Address
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Address Line | 100 GRAND ST ONDREA CHASSE, MEDICAL STAFF OFFICE
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City | NEW BRITAIN
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State | CT
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Zip | 06052-2016
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Country | US
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Telephone | 860-224-5305
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Fax | 860-224-5950
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Provider Business Mailing Address
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Address Line | 100 GRAND ST
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City | NEW BRITAIN
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State | CT
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Zip | 06052-2016
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Country | US
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Telephone | 860-224-5510
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Fax | 860-224-5950
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RI0200X
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Taxonomy Name | Infectious Disease Physician
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License Number | 032904
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License Number State | CT
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