Provider Demographics
NPI:1447260898
Name:CLARK, JENNIFER ALICIA (RPH)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:ALICIA
Last Name:CLARK
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1613 CAMBRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02138-4315
Mailing Address - Country:US
Mailing Address - Phone:617-354-5600
Mailing Address - Fax:617-492-8135
Practice Address - Street 1:1613 CAMBRIDGE ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-4315
Practice Address - Country:US
Practice Address - Phone:617-354-5600
Practice Address - Fax:617-492-8135
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA23496183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist