MEDICARE: JENNIJO CLARK LPN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	313347-31	WI

General Provider Information

NPI Number	:	1265734354
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIJO CLARK LPN

Provider Business Mailing Address
First Line	:	402 W SOUTH PARK AVE
Second Line	:
City	:	OSHKOSH
State	:	WI
Zip	:	54902-6569
Country	:	US
Telephone Number	:	920-203-9055
Fax Number	:

Provider Business Practice Location Address
First Line	:	402 W SOUTH PARK AVE
Second Line	:
City	:	OSHKOSH
State	:	WI
Zip	:	54902-6569
Country	:	US
Telephone Number	:	920-203-9055
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/23/2010
Last Update Date	:	11/23/2010

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Directions to “ JENNIJO CLARK LPN” Practice Location

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