Provider Demographics
NPI:1053444331
Name:CLARK, JENNIFER (LICSW)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:184 CROSS ST
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01890-1118
Mailing Address - Country:US
Mailing Address - Phone:508-414-3890
Mailing Address - Fax:
Practice Address - Street 1:6 PLEASANT ST
Practice Address - Street 2:6TH FLOOR
Practice Address - City:MALDEN
Practice Address - State:MA
Practice Address - Zip Code:02148-5100
Practice Address - Country:US
Practice Address - Phone:781-322-1503
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1133391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical