Provider Demographics
NPI:1932314887
Name:CLARK, JENNIFER (LMFT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:531 26TH AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95062-5321
Mailing Address - Country:US
Mailing Address - Phone:831-425-4422
Mailing Address - Fax:
Practice Address - Street 1:104 WALNUT AVE
Practice Address - Street 2:STE 208
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-3900
Practice Address - Country:US
Practice Address - Phone:831-423-9444
Practice Address - Fax:861-423-1532
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2009-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT47522106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA49809OtherINTERN NUMBER
CAMFT47522OtherLICENSED MARRIAGE AND FAMILY THERAPIST