Provider Demographics
NPI:1740745066
Name:CLARK, JONNA L
Entity Type:Individual
Prefix:
First Name:JONNA
Middle Name:L
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 1:19 BECKFORD ST APT 1
Mailing Address - Street 2:
Mailing Address - City:BEVERLY
Mailing Address - State:MA
Mailing Address - Zip Code:01915-3136
Mailing Address - Country:US
Mailing Address - Phone:603-581-6209
Mailing Address - Fax:
Practice Address - Street 1:19 BECKFORD ST APT 1
Practice Address - Street 2:
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915-3136
Practice Address - Country:US
Practice Address - Phone:603-581-6209
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-31
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor