Healthcare Provider Details

I. General information

NPI: 1750409249
Provider Name (Legal Business Name): JANELLE CLARK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 04/21/2024
Certification Date: 04/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

686 W LINE ST
BISHOP CA
93514-3315
US

IV. Provider business mailing address

PO BOX 823
BISHOP CA
93515-0823
US

V. Phone/Fax

Practice location:
  • Phone: 805-570-9375
  • Fax:
Mailing address:
  • Phone: 805-570-3750
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number52043
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number30993
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: