Provider Demographics
NPI:1366001810
Name:CLARK, TEMPA TEMERA DOMINIQUE
Entity Type:Individual
Prefix:MS
First Name:TEMPA TEMERA
Middle Name:DOMINIQUE
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:PO BOX 701
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39060-0701
Mailing Address - Country:US
Mailing Address - Phone:601-473-2106
Mailing Address - Fax:601-473-2150
Practice Address - Street 1:604 HIGHWAY 80 W STE R
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MS
Practice Address - Zip Code:39056-4108
Practice Address - Country:US
Practice Address - Phone:601-473-2106
Practice Address - Fax:601-473-2150
Is Sole Proprietor?:No
Enumeration Date:2019-06-09
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101Y00000XBehavioral Health & Social Service ProvidersCounselor