Basic Information
| Provider Information | |||||||||
| NPI: | 1134756802 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARKE | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 281814 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303841814 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 500 HIOAKS RD STE B | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232254061 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8045600490 | ||||||||
| FaxNumber: | 8045603424 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2020 | ||||||||
| LastUpdateDate: | 04/28/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 0024178855 | VA | N | Allopathic & Osteopathic Physicians | Family Medicine | 363L00000X | 0024178855 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.