Provider Demographics
NPI:1073799938
Name:CLARK, HEATHER JORDON (PHD)
Entity Type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:JORDON
Last Name:CLARK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2124 NE 65TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-1010
Mailing Address - Country:US
Mailing Address - Phone:754-800-2345
Mailing Address - Fax:
Practice Address - Street 1:2124 NE 65TH ST
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-1010
Practice Address - Country:US
Practice Address - Phone:754-800-2345
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-10
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY7620103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical