MEDICARE: MRS. VALERIE JORDAN CLARK LPC

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	101YP2500X	Professional Counselor	0701003751	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	O802295M	OTHER	VA	SENTARA-OPTIMA-OFC
2	010264359	OTHER	VA	VIRGINIA PREMIER HEALTH
3	197565	OTHER	VA	ANTHEM BLUE CROSS BLUE SH
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1679504997
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. VALERIE JORDAN CLARK LPC

Provider Business Mailing Address
First Line	:	5361A VIRGINIA BEACH BLVD
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23462-1897
Country	:	US
Telephone Number	:	757-456-2366
Fax Number	:	757-456-2367

Provider Business Practice Location Address
First Line	:	4855 PRINCESS ANNE RD
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23462-4446
Country	:	US
Telephone Number	:	757-467-7707
Fax Number	:	757-495-3206

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/05/2006
Last Update Date	:	04/25/2009

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