Provider Demographics
NPI:1851006407
Name:CLARK, JONI
Entity Type:Individual
Prefix:
First Name:JONI
Middle Name:
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 1:14 S MAIN ST STE 1E
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:SD
Mailing Address - Zip Code:57401-4189
Mailing Address - Country:US
Mailing Address - Phone:605-225-1010
Mailing Address - Fax:605-725-8055
Practice Address - Street 1:14 S MAIN ST STE 1E
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:SD
Practice Address - Zip Code:57401-4189
Practice Address - Country:US
Practice Address - Phone:605-225-1010
Practice Address - Fax:605-725-8055
Is Sole Proprietor?:No
Enumeration Date:2023-01-18
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
SDLPC20806101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor