Jennifer Diane Clark, MD

Primary specialty

Pediatrics PhysicianTaxonomy code 208000000X

License

MD23961 Issued in ME

Practice address

14732 Village Square PL
Midlothian, VA 23112-2253

Phone

(804) 639-0717

Fax

(804) 639-0767

NPI assigned

Apr 10, 2006

Last updated

Jan 28, 2021By the provider in NPPES

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Other identifiers 13

Medicare fee-for-service enrollment

Enrolled in ME

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Woodlake Village Pediatrics LLC

  • Specialist
  • Midlothian, VA
  • NPI 1578681946
  NPD (past) Authorized official
• Virginia Emergency Physicians LLP

  • Emergency Medicine Physician
  • Richmond, VA
  • NPI 1134475999
  NPD (past)
• Virginia Emergency Physicians LLP

  • Emergency Medicine Physician
  • Richmond, VA
  • NPI 1639193188
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1144627200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1611792000000",
    "number": "1871556878",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "14732 VILLAGE SQUARE PL",
            "city": "MIDLOTHIAN",
            "state": "VA",
            "postal_code": "231122253",
            "telephone_number": "804-639-0717",
            "fax_number": "804-639-0767"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "14732 VILLAGE SQUARE PL",
            "city": "MIDLOTHIAN",
            "state": "VA",
            "postal_code": "231122253",
            "telephone_number": "804-639-0717",
            "fax_number": "804-639-0767"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "CLARK",
        "first_name": "JENNIFER",
        "middle_name": "DIANE",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2006-04-10",
        "last_updated": "2021-01-28",
        "certification_date": "2021-01-28",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": "VA",
            "license": "0101 056329",
            "primary": false
        },
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": "ME",
            "license": "MD23961",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "010121086",
            "state": "VA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CIGNA",
            "identifier": "4768718",
            "state": "VA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "AETNA PPO",
            "identifier": "5214032",
            "state": "VA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "ANTHEM BCBS",
            "identifier": "171941",
            "state": "VA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PHCS",
            "identifier": "432058755",
            "state": "VA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "SOUTHERN HEALTH",
            "identifier": "299592",
            "state": "VA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "GREAT WEST",
            "identifier": "432058755",
            "state": "VA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "OPTIMA HEALTH",
            "identifier": "10007264",
            "state": "VA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "UNITED HEALTH CARE",
            "identifier": "1240927",
            "state": "VA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "AETNA HMO",
            "identifier": "3649627",
            "state": "VA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "FIRST HEALTH NETWORK",
            "identifier": "1382954",
            "state": "VA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "TRICARE",
            "identifier": "432058755",
            "state": "VA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "FHN PRODUCT, CCN",
            "identifier": "5056305",
            "state": "VA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Christopher Cios, D.D.S.
• Craig Clamp
• Aaron David Clampitt
• Andrew Byler Clark
• James Jacob Clark, LPC
• Donna Celene Clarke, PMHNP
• Keith Weathers Clarke, RPH
• Sharon J Clarke, FNP
• Christine Cleary
• Debra Lynn Clements, RPH

• Pediatrics Physician in Midlothian, VA
• Providers in Midlothian, VA by specialty
• Pediatrics Physician in Virginia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 28, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.