Healthcare Provider Details

I. General information

NPI: 1023146651
Provider Name (Legal Business Name): JANE ANNE CLARKE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BLDG 1576 MASSEY AVE
NS MAYPORT FL
32228-0042
US

IV. Provider business mailing address

12216 LAKE FERN DR E
JACKSONVILLE FL
32258-5388
US

V. Phone/Fax

Practice location:
  • Phone: 904-270-6600
  • Fax: 904-270-5094
Mailing address:
  • Phone: 904-886-8394
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC303204
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: