Healthcare Provider Details

I. General information

NPI: 1225860646
Provider Name (Legal Business Name): JENNIFER STEWART CLARK MSWI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2024
Last Update Date: 08/15/2024
Certification Date: 08/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2046 E MURRAY HOLLADAY RD STE 101
HOLLADAY UT
84117-5173
US

IV. Provider business mailing address

934 E LORRAINE AVE
SALT LAKE CITY UT
84106-2045
US

V. Phone/Fax

Practice location:
  • Phone: 801-980-2566
  • Fax:
Mailing address:
  • Phone: 801-244-3269
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: