Basic Information
| Provider Information | |||||||||
| NPI: | 1154576130 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | TERRI | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2809 FOREST HOME RD | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724015320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8669721268 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2200 E MATTHEWS AVE | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724014347 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8709721268 | ||||||||
| FaxNumber: | 8709340847 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/18/2008 | ||||||||
| LastUpdateDate: | 08/30/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 6664-M | AR | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 191510795 | 05 | AR | MEDICAID |