Individual
MS. JENNIFER ANN CLARK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
330 WARNER DR, LEWISTON, ID 83501-4441
(208) 746-0193
(208) 746-7074
Mailing address
330 WARNER DR, LEWISTON, ID 83501-4441
(208) 746-0193
(208) 746-7074
Taxonomy
Speciality
Code
Description
License number
State
231H00000X
Audiologist
Primary
AUD-1728
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010170154
REGENCE BLUESHIELD OF ID
ID
01
—
1580017
MEDICARE ID
ID
05
—
808195700
—
ID
05
—
8560278
—
WA
01
—
AU022
BLUE CROSS OF ID
ID
01
—
P00678807
RAILROAD MEDICARE
ID
Enumeration date
04/09/2008
Last updated
04/28/2010
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