Healthcare Provider Details

I. General information

NPI: 1417861865
Provider Name (Legal Business Name): JENNIFER CLARK LCPC, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/01/2026
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

76 LINCOLN AVE
GARDINER ME
04345-2518
US

IV. Provider business mailing address

76 LINCOLN AVE
GARDINER ME
04345-2518
US

V. Phone/Fax

Practice location:
  • Phone: 207-441-5141
  • Fax:
Mailing address:
  • Phone: 207-441-5141
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number37PC01223500
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCC8672
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: