Provider Demographics
NPI:1053584292
Name:CLARK, JENNIFER ANN
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:ANN
Last Name:CLARK
Suffix:
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 1:330 WARNER DR
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-4441
Mailing Address - Country:US
Mailing Address - Phone:208-746-0193
Mailing Address - Fax:208-746-7074
Practice Address - Street 1:330 WARNER DR
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-4441
Practice Address - Country:US
Practice Address - Phone:208-746-0193
Practice Address - Fax:208-746-7074
Is Sole Proprietor?:No
Enumeration Date:2008-04-09
Last Update Date:2010-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDAUD-1728231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDAU022OtherBLUE CROSS OF ID
ID000010170154OtherREGENCE BLUESHIELD OF ID
WA8560278Medicaid
ID808195700Medicaid
ID1580017OtherMEDICARE ID
IDP00678807OtherRAILROAD MEDICARE