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General NPI Number Information
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NPI Number | 1447916572
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Entity Type | Individual
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Provider Name | JENNIFER R CLARK PSYD
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Gender | Female
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Dates
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Enumeration Date | 11/12/2021
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Last Update Date | 11/12/2021
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Provider Practice Location Address
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Address Line | 1220 SW MORRISON ST STE 929
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City | PORTLAND
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State | OR
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Zip | 97205-2228
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Country | US
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Telephone | 503-994-8811
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 8865
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City | PORTLAND
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State | OR
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Zip | 97207-8865
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 2632
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License Number State | OR
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