Basic Information
| Provider Information | |||||||||
| NPI: | 1407290885 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | FAYE | ||||||||
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| Credential: | R.N. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1923 SULPHUR SPRINGS RD DEPT 100 | ||||||||
| Address2: | |||||||||
| City: | MORRISTOWN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378135654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4233179344 | ||||||||
| FaxNumber: | 4237142355 | ||||||||
| Practice Location | |||||||||
| Address1: | 255 E WATT ST | ||||||||
| Address2: | |||||||||
| City: | ALCOA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 377012236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8652731616 | ||||||||
| FaxNumber: | 8652731645 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2013 | ||||||||
| LastUpdateDate: | 06/17/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0808X | RN165443 | TN | N | Nursing Service Providers | Registered Nurse | Psych/Mental Health | 163W00000X | 165443 | TN | Y | Nursing Service Providers | Registered Nurse |
No ID Information.