Provider Demographics
NPI:1508469537
Name:CLARK SHIFRIN, JAYLYN (PHD)
Entity Type:Individual
Prefix:DR
First Name:JAYLYN
Middle Name:
Last Name:CLARK SHIFRIN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 WHITCHER ST NE STE 420
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-1171
Mailing Address - Country:US
Mailing Address - Phone:770-514-6760
Mailing Address - Fax:770-794-8034
Practice Address - Street 1:55 WHITCHER ST NE STE 420
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1171
Practice Address - Country:US
Practice Address - Phone:770-514-6760
Practice Address - Fax:770-794-8034
Is Sole Proprietor?:No
Enumeration Date:2020-11-20
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5826103T00000X, 103TC0700X, 103TH0004X
GAPSY004638103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5826OtherNORTH CAROLINA PSYCHOLOGY BOARD