Provider Demographics
NPI:1245953199
Name:CLARK, JENNIFER ANNE (LCPC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANNE
Last Name:CLARK
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2071 N SOUTHPORT AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-4015
Mailing Address - Country:US
Mailing Address - Phone:888-428-7890
Mailing Address - Fax:
Practice Address - Street 1:2071 N SOUTHPORT AVE STE 100
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-4015
Practice Address - Country:US
Practice Address - Phone:509-436-6625
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-26
Last Update Date:2025-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.018157101YP2500X
IL180016757101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional