Provider Demographics
NPI:1700476678
Name:CLARK, JENNIFER
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
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:PO BOX 41053
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89504-5053
Mailing Address - Country:US
Mailing Address - Phone:775-337-6566
Mailing Address - Fax:775-997-5213
Practice Address - Street 1:542 LANDER ST
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89509-1551
Practice Address - Country:US
Practice Address - Phone:775-337-6566
Practice Address - Fax:775-996-5213
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-24
Last Update Date:2021-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV02327-I101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)