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General NPI Number Information
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NPI Number | 1528426343
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Entity Type | Organization
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Legal Business Name | DR JANE CLARK LLC
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Dates
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Enumeration Date | 02/08/2016
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Last Update Date | 02/08/2016
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Provider Practice Location Address
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Address Line | 15 MEADOW ST
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City | LITCHFIELD
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State | CT
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Zip | 06759-3504
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Country | US
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Telephone | 860-490-0800
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Fax | 888-859-4374
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Provider Business Mailing Address
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Address Line | 2 KEYSTONE CIR
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City | AVON
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State | CT
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Zip | 06001-3312
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Country | US
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Telephone | 860-490-0800
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Fax | 888-859-4374
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Authorized Official
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Title or Position | APRN
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Name | DR. JANE ELIZABETH CLARK
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Credential | DNSC, MS
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Telephone | 860-490-0800
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 001952
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License Number State | CT
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