Individual
JENNIFER DIANE CLARK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
14732 VILLAGE SQUARE PL, MIDLOTHIAN, VA 23112-2253
(804) 639-0717
(804) 639-0767
Mailing address
14732 VILLAGE SQUARE PL, MIDLOTHIAN, VA 23112-2253
(804) 639-0717
(804) 639-0767
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
0101 056329
VA
208000000X
Pediatrics Physician
Primary
MD23961
ME
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
010121086
—
VA
01
—
10007264
OPTIMA HEALTH
VA
01
—
1240927
UNITED HEALTH CARE
VA
01
—
1382954
FIRST HEALTH NETWORK
VA
01
—
171941
ANTHEM BCBS
VA
01
—
299592
SOUTHERN HEALTH
VA
01
—
3649627
AETNA HMO
VA
01
—
432058755
TRICARE
VA
01
—
4768718
CIGNA
VA
01
—
5056305
FHN PRODUCT, CCN
VA
01
—
5214032
AETNA PPO
VA
Enumeration date
04/10/2006
Last updated
01/28/2021
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