Provider Demographics
NPI:1871363853
Name:CLARK, JAN CHRISTINE (TLMHC)
Entity type:Individual
Prefix:MS
First Name:JAN
Middle Name:CHRISTINE
Last Name:CLARK
Suffix:
Gender:F
Credentials:TLMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:301 W BURLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:IA
Mailing Address - Zip Code:52556-3242
Mailing Address - Country:US
Mailing Address - Phone:641-472-1864
Mailing Address - Fax:641-472-4609
Practice Address - Street 1:509 AVENUE F
Practice Address - Street 2:
Practice Address - City:FORT MADISON
Practice Address - State:IA
Practice Address - Zip Code:52627-2910
Practice Address - Country:US
Practice Address - Phone:319-372-3566
Practice Address - Fax:319-372-8074
Is Sole Proprietor?:No
Enumeration Date:2024-01-02
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA123568101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health