Provider Demographics
NPI:1871556878
Name:CLARK, JENNIFER DIANE (MD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:DIANE
Last Name:CLARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14732 VILLAGE SQUARE PL
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112-2253
Mailing Address - Country:US
Mailing Address - Phone:804-639-0717
Mailing Address - Fax:804-639-0767
Practice Address - Street 1:14732 VILLAGE SQUARE PL
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-2253
Practice Address - Country:US
Practice Address - Phone:804-639-0717
Practice Address - Fax:804-639-0767
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101 056329208000000X
MEMD23961208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA432058755OtherTRICARE
VA1382954OtherFIRST HEALTH NETWORK
VA010121086Medicaid
VA10007264OtherOPTIMA HEALTH
VA1240927OtherUNITED HEALTH CARE
VA171941OtherANTHEM BCBS
VA5056305OtherFHN PRODUCT, CCN
VA299592OtherSOUTHERN HEALTH
VA5214032OtherAETNA PPO
VA432058755OtherGREAT WEST
VA3649627OtherAETNA HMO
VA4768718OtherCIGNA
VA432058755OtherPHCS
VA010121086Medicaid