Healthcare Provider Details

I. General information

NPI: 1851880926
Provider Name (Legal Business Name): JENISE TRANNELL CLARK LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2018
Last Update Date: 03/22/2021
Certification Date: 03/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

715 BRADLEY DR
FAYETTEVILLE GA
30214-2030
US

IV. Provider business mailing address

3777 WALDROP LN
DECATUR GA
30034-6786
US

V. Phone/Fax

Practice location:
  • Phone: 770-358-5252
  • Fax:
Mailing address:
  • Phone: 404-274-0929
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: