Basic Information
| Provider Information | |||||||||
| NPI: | 1295319374 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | SHAE | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1371 COUNTY ROAD 1340 | ||||||||
| Address2: | |||||||||
| City: | CHICO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 764312625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3252623319 | ||||||||
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| Practice Location | |||||||||
| Address1: | 800 MEDICAL CENTER DR STE C | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | TX | ||||||||
| PostalCode: | 762343844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9406262110 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2021 | ||||||||
| LastUpdateDate: | 05/05/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 1010436 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.