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General NPI Number Information
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NPI Number | 1912049594
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Entity Type | Individual
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Provider Name | ALETHA JENNIFER CLARK PHD, LPC
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Gender | Female
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Dates
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Enumeration Date | 02/12/2007
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Last Update Date | 02/06/2024
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Provider Practice Location Address
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Address Line | 2386 CLOWER ST STE D-100
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City | SNELLVILLE
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State | GA
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Zip | 30078-6134
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Country | US
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Telephone | 404-550-0564
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Fax | 678-344-2956
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Provider Business Mailing Address
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Address Line | PO BOX 955
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City | SNELLVILLE
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State | GA
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Zip | 30078-0955
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Country | US
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Telephone | 404-550-0564
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Fax | 678-344-2956
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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 | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 1658-R
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | LPC004805
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License Number State | GA
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