Provider Demographics
NPI:1679062293
Name:CLARK, JASMIN DESRIE
Entity Type:Individual
Prefix:
First Name:JASMIN
Middle Name:DESRIE
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 1:125 BROAD ST,
Mailing Address - Street 2:3 RD FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10004
Mailing Address - Country:US
Mailing Address - Phone:917-580-0179
Mailing Address - Fax:
Practice Address - Street 1:11578 LEFFERTS BLVD # 2
Practice Address - Street 2:
Practice Address - City:SOUTH OZONE PARK
Practice Address - State:NY
Practice Address - Zip Code:11420-2406
Practice Address - Country:US
Practice Address - Phone:646-281-7793
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-09
Last Update Date:2018-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNYCPS-P-2029101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health