Provider Demographics
NPI:1518684232
Name:CLARK, JEANNINE PEARCE
Entity Type:Individual
Prefix:
First Name:JEANNINE
Middle Name:PEARCE
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 1:271 IMPERIAL LN
Mailing Address - Street 2:
Mailing Address - City:LAUDERDALE BY THE SEA
Mailing Address - State:FL
Mailing Address - Zip Code:33308-5924
Mailing Address - Country:US
Mailing Address - Phone:954-478-9328
Mailing Address - Fax:
Practice Address - Street 1:271 IMPERIAL LN
Practice Address - Street 2:
Practice Address - City:LAUDERDALE BY THE SEA
Practice Address - State:FL
Practice Address - Zip Code:33308-5924
Practice Address - Country:US
Practice Address - Phone:954-478-9328
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-24
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL22609101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL46-3082537Medicaid
FL101YM0800XMedicaid