Provider Demographics
NPI:1235503004
Name:CLARK, CAROL JONES (MS CCC SLP)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:JONES
Last Name:CLARK
Suffix:
Gender:F
Credentials:MS CCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 ROSELAWN AVE
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55117
Mailing Address - Country:US
Mailing Address - Phone:651-793-3338
Mailing Address - Fax:
Practice Address - Street 1:550 ROSELAWN AVE E
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55117-2120
Practice Address - Country:US
Practice Address - Phone:651-793-3338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-17
Last Update Date:2015-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8556235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist