Provider Demographics
NPI:1720131493
Name:CLARK, JANICE MARIE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:JANICE
Middle Name:MARIE
Last Name:CLARK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:JANICE
Other - Middle Name:MARIE
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:602 LOOKING GLASS AVE
Mailing Address - Street 2:
Mailing Address - City:OFFUTT AFB
Mailing Address - State:NE
Mailing Address - Zip Code:68113-3112
Mailing Address - Country:US
Mailing Address - Phone:402-294-3071
Mailing Address - Fax:
Practice Address - Street 1:2501 CAPEHART ROAD
Practice Address - Street 2:55TH MDG
Practice Address - City:BELLEVUE
Practice Address - State:NE
Practice Address - Zip Code:68123
Practice Address - Country:US
Practice Address - Phone:402-294-3071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOSW0009431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000078678Medicare UPIN