Provider Demographics
NPI:1164799870
Name:CLARKE, JEANETTE (SLP, TSSLD)
Entity Type:Individual
Prefix:
First Name:JEANETTE
Middle Name:
Last Name:CLARKE
Suffix:
Gender:F
Credentials:SLP, TSSLD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 431
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:10552-0431
Mailing Address - Country:US
Mailing Address - Phone:646-283-4353
Mailing Address - Fax:
Practice Address - Street 1:2386 MORRIS AVE
Practice Address - Street 2:APT. 5E
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10468-6645
Practice Address - Country:US
Practice Address - Phone:646-283-4353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-23
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021512235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist