Provider Demographics
NPI:1477841039
Name:CLARK, JENNIFER J (PLMHP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:J
Last Name:CLARK
Suffix:
Gender:F
Credentials:PLMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5701 THOMPSON CREEK BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68516-5661
Mailing Address - Country:US
Mailing Address - Phone:402-580-0019
Mailing Address - Fax:
Practice Address - Street 1:5701 THOMPSON CREEK BLVD STE 200
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68516-5661
Practice Address - Country:US
Practice Address - Phone:402-580-0019
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-18
Last Update Date:2011-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10026039600Medicaid