Provider Demographics
NPI:1326356247
Name:CLARK, TRACY ANN (LCSW)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:ANN
Last Name:CLARK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:ANN
Other - Last Name:HORTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1804 HIGHWAY 45 BYP
Mailing Address - Street 2:SUITE 604
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-4436
Mailing Address - Country:US
Mailing Address - Phone:731-512-1571
Mailing Address - Fax:731-660-8739
Practice Address - Street 1:238 SUMMAR DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-3906
Practice Address - Country:US
Practice Address - Phone:731-927-7628
Practice Address - Fax:731-927-7642
Is Sole Proprietor?:No
Enumeration Date:2010-09-14
Last Update Date:2010-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN7211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical