Basic Information
| Provider Information | |||||||||
| NPI: | 1003298639 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | JEANETTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3605 CHASEWOOD DR SW APT 5 | ||||||||
| Address2: | |||||||||
| City: | HUNTSVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 358055180 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2054276509 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1803 N. JACKSON ST | ||||||||
| Address2: | CENTERSTONE OF TENNESSEE | ||||||||
| City: | TULLAHOMA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37388 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6154636643 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2015 | ||||||||
| LastUpdateDate: | 06/19/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YS0200X | Y | Behavioral Health & Social Service Providers | Counselor | School |
No ID Information.