Provider Demographics
NPI:1629561410
Name:CLARK, JENNA (LSCSW)
Entity Type:Individual
Prefix:MRS
First Name:JENNA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:LSCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1214 N BUCKEYE AVE
Mailing Address - Street 2:
Mailing Address - City:ABILENE
Mailing Address - State:KS
Mailing Address - Zip Code:67410-1943
Mailing Address - Country:US
Mailing Address - Phone:229-457-0730
Mailing Address - Fax:
Practice Address - Street 1:1214 N BUCKEYE AVE
Practice Address - Street 2:
Practice Address - City:ABILENE
Practice Address - State:KS
Practice Address - Zip Code:67410-1943
Practice Address - Country:US
Practice Address - Phone:229-457-0730
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-07
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS10032104100000X
KS49301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker