Basic Information
| Provider Information | |||||||||
| NPI: | 1386908150 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARKE | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | AU.D CCC-A | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PACCHIANA | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | AUD CCC-A | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 104 WOODMONT BLVD | ||||||||
| Address2: | LL50 | ||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372052245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153862398 | ||||||||
| FaxNumber: | 6153862399 | ||||||||
| Practice Location | |||||||||
| Address1: | 4230 HARDING PIKE | ||||||||
| Address2: | STE 400 | ||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372052013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152972700 | ||||||||
| FaxNumber: | 6153862399 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2012 | ||||||||
| LastUpdateDate: | 05/12/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | 1659 | TN | Y | Speech, Language and Hearing Service Providers | Audiologist |
ID Information
| ID | Type | State | Issuer | Description | 1532846 | 05 | TN | MEDICAID | 4360888 | 01 | TN | BLUECROSS BLUESHIELD TN | OTHER |