Provider Demographics
NPI:1003298639
Name:CLARK, JEANETTA
Entity Type:Individual
Prefix:
First Name:JEANETTA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3605 CHASEWOOD DR SW APT 5
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35805-5180
Mailing Address - Country:US
Mailing Address - Phone:205-427-6509
Mailing Address - Fax:
Practice Address - Street 1:1803 N. JACKSON ST
Practice Address - Street 2:CENTERSTONE OF TENNESSEE
Practice Address - City:TULLAHOMA
Practice Address - State:TN
Practice Address - Zip Code:37388
Practice Address - Country:US
Practice Address - Phone:615-463-6643
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-19
Last Update Date:2015-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool