Basic Information
| Provider Information | |||||||||
| NPI: | 1154844678 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | RICHARDS | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | APRN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HUNT | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 784 HIGHWAY 36 | ||||||||
| Address2: | |||||||||
| City: | FRENCHBURG | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403228123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6067689190 | ||||||||
| FaxNumber: | 6067689180 | ||||||||
| Practice Location | |||||||||
| Address1: | 784 HIGHWAY 36 | ||||||||
| Address2: | |||||||||
| City: | FRENCHBURG | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403228123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6067689190 | ||||||||
| FaxNumber: | 6067689180 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2017 | ||||||||
| LastUpdateDate: | 03/21/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 3011173 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 3011173 | 01 | KY | APRN LICENSE | OTHER |