Provider Demographics
NPI:1417028937
Name:CLARK, JENNIFER (LCSW)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 LIBERTY RD
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:CT
Mailing Address - Zip Code:06370-1211
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:72 ROUTE 32
Practice Address - Street 2:
Practice Address - City:NORTH FRANKLIN
Practice Address - State:CT
Practice Address - Zip Code:06254-1810
Practice Address - Country:US
Practice Address - Phone:860-917-0790
Practice Address - Fax:860-367-0342
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0060601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical