Provider Demographics
NPI:1861996217
Name:CLARK, JENNIFFER COLLEEN I
Entity type:Individual
Prefix:
First Name:JENNIFFER
Middle Name:COLLEEN
Last Name:CLARK
Suffix:I
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 HARBOR RD
Mailing Address - Street 2:
Mailing Address - City:GROVE
Mailing Address - State:OK
Mailing Address - Zip Code:74344-7918
Mailing Address - Country:US
Mailing Address - Phone:918-786-4434
Mailing Address - Fax:
Practice Address - Street 1:1115 HAR-BER RD
Practice Address - Street 2:
Practice Address - City:GROVE
Practice Address - State:OK
Practice Address - Zip Code:74344
Practice Address - Country:US
Practice Address - Phone:918-786-4434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-21
Last Update Date:2018-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator