Provider Demographics
NPI:1902404460
Name:CLARK, BRITTANY C
Entity Type:Individual
Prefix:
First Name:BRITTANY
Middle Name:C
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 1:107 GREENFIELD WAY
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-8108
Mailing Address - Country:US
Mailing Address - Phone:601-479-8669
Mailing Address - Fax:
Practice Address - Street 1:3450 HIGHWAY 80 W
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39209-7201
Practice Address - Country:US
Practice Address - Phone:601-321-2400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-15
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MS2941101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health