Clark, Jennifer Diane

Clark, Jennifer Diane is an individual health care provider with primary practice located at 14732 Village Square Pl , Midlothian VA 23112-2253. She recently has only one registered license in Allopathic & Osteopathic Physicians / Pediatrics, which is considered as her primary health care specialty. Clark, Jennifer Diane can be contacted via phone (804) 639-0717.

Contact Information

Primary practice address
14732 Village Square Pl Midlothian VA 23112-2253
Phone: (804) 639-0717
Fax: (804) 639-0767
Website:
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Health care specialties

SpecialtyCodeLicense #State
Allopathic & Osteopathic Physicians / Pediatrics 208000000X 0101 056329 Virginia
Allopathic & Osteopathic Physicians / Pediatrics 208000000X MD23961 Maine

Profile Details

NPI number 1871556878
LBN Legal business name Clark, Jennifer Diane
Credentials Doctor of Medicine (MD)
Entity Individual
Sole proprietor 1 No
Enumeration date Apr 10th, 2006
Last updated Jan 28th, 2021 - about 4 years ago

1 A sole proprietor/sole proprietorship is an individual, and in that capacity, is qualified for a solitary NPI number. The sole proprietor have to apply for the NPI number using his or her own particular Social Security Number (SSN), instead of Employer Identification Number (EIN) regardless of whether he/she has an EIN.

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Identifiers

StateTypeNumberIssuer
All States NPI 1871556878 NPPES
Virginia Other 432058755 TRICARE
Virginia Other 1382954 TRICARE
Virginia MEDICAID 010121086 TRICARE
Virginia Other 10007264 TRICARE
Virginia Other 1240927 TRICARE
Virginia Other 171941 TRICARE
Virginia Other 5056305 TRICARE
Virginia Other 299592 TRICARE
Virginia Other 5214032 TRICARE
Virginia Other 432058755 TRICARE
Virginia Other 3649627 TRICARE
Virginia Other 4768718 TRICARE
Virginia Other 432058755 TRICARE

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