MEDICARE: DR JANE CLARK LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	001952	CT

General Provider Information

NPI Number	:	1528426343
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DR JANE CLARK LLC

Provider Business Mailing Address
First Line	:	2 KEYSTONE CIR
Second Line	:
City	:	AVON
State	:	CT
Zip	:	06001-3312
Country	:	US
Telephone Number	:	860-490-0800
Fax Number	:	888-859-4374

Provider Business Practice Location Address
First Line	:	15 MEADOW ST
Second Line	:
City	:	LITCHFIELD
State	:	CT
Zip	:	06759-3504
Country	:	US
Telephone Number	:	860-490-0800
Fax Number	:	888-859-4374

Authorized Official
Title or Position	:	APRN
Name	:	DR. JANE ELIZABETH CLARK
Credential	:	DNSC, MS
Telephone Number	:	860-490-0800

Provider Enumeration Date	:	02/08/2016
Last Update Date	:	02/08/2016

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