Provider Demographics
NPI:1962010314
Name:CLARKE, JACLYN
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:CLARKE
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 1:1245 COAN ST
Mailing Address - Street 2:
Mailing Address - City:BURNS HARBOR
Mailing Address - State:IN
Mailing Address - Zip Code:46304-9764
Mailing Address - Country:US
Mailing Address - Phone:773-322-7075
Mailing Address - Fax:
Practice Address - Street 1:1245 COAN ST
Practice Address - Street 2:
Practice Address - City:BURNS HARBOR
Practice Address - State:IN
Practice Address - Zip Code:46304-9764
Practice Address - Country:US
Practice Address - Phone:773-322-7075
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-21
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor