Provider Demographics
NPI:1205087657
Name:CLARK-JEFFERIES, TAKENYA CHIMENE (LCSW)
Entity type:Individual
Prefix:
First Name:TAKENYA
Middle Name:CHIMENE
Last Name:CLARK-JEFFERIES
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:TAKENYA
Other - Middle Name:CHIMENE
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSW
Mailing Address - Street 1:PO BOX 1361
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:CA
Mailing Address - Zip Code:92316-0380
Mailing Address - Country:US
Mailing Address - Phone:909-452-5857
Mailing Address - Fax:909-527-4813
Practice Address - Street 1:12139 MOUNT VERNON AVE STE 104
Practice Address - Street 2:
Practice Address - City:GRAND TERRACE
Practice Address - State:CA
Practice Address - Zip Code:92313-5500
Practice Address - Country:US
Practice Address - Phone:909-452-5857
Practice Address - Fax:909-527-4811
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-03
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS#62241104100000X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker