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General NPI Number Information
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NPI Number | 1962918417
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Entity Type | Individual
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Provider Name | MS. JENNIFER LYNN PEACOCK CLARK
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Gender | Female
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Dates
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Enumeration Date | 12/20/2017
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Last Update Date | 03/03/2021
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Provider Practice Location Address
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Address Line | 173 MESEROLE AVE APT 2L
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City | BROOKLYN
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State | NY
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Zip | 11222-2424
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Country | US
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Telephone | 646-256-2104
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Fax |
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Provider Business Mailing Address
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Address Line | 173 MESEROLE AVE APT 2L
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City | BROOKLYN
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State | NY
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Zip | 11222-2424
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Country | US
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Telephone |
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Fax |
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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 | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | 561419
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 363LA2200X
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Taxonomy Name | Adult Health Nurse Practitioner
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License Number | 308588
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License Number State | NY
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