Provider Demographics
NPI:1902231210
Name:CLARK, CASANDRA JEWEL
Entity Type:Individual
Prefix:
First Name:CASANDRA
Middle Name:JEWEL
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 1:15251 PLEASANT VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:CENTER CITY
Mailing Address - State:MN
Mailing Address - Zip Code:55012-9640
Mailing Address - Country:US
Mailing Address - Phone:651-213-4184
Mailing Address - Fax:
Practice Address - Street 1:8682 INWOOD AVE S
Practice Address - Street 2:
Practice Address - City:COTTAGE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55016-4716
Practice Address - Country:US
Practice Address - Phone:651-341-9660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-05
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP5929103TC0700X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical