Provider Demographics
NPI:1528417078
Name:CLARK, ELIZABETH JAZZ (TLMHC)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:JAZZ
Last Name:CLARK
Suffix:
Gender:F
Credentials:TLMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1030 5TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52403-2464
Mailing Address - Country:US
Mailing Address - Phone:319-286-4545
Mailing Address - Fax:
Practice Address - Street 1:1030 5TH AVE SE
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52403
Practice Address - Country:US
Practice Address - Phone:319-286-4545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-06
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA082944101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health