Provider Demographics
NPI:1851756126
Name:CLARKE, JADA (BS)
Entity Type:Individual
Prefix:
First Name:JADA
Middle Name:
Last Name:CLARKE
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:608 SOUTH AVE SW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-4218
Mailing Address - Country:US
Mailing Address - Phone:706-233-9023
Mailing Address - Fax:706-232-6099
Practice Address - Street 1:6 MATHIS DR NW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-1242
Practice Address - Country:US
Practice Address - Phone:706-233-9023
Practice Address - Fax:706-232-6099
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-30
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1014M0800XMedicaid