Provider Demographics
NPI:1083401517
Name:CLARK, JENNA MICHELLE (LPCC)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:MICHELLE
Last Name:CLARK
Suffix:
Gender:
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1492 HAZEL ST N
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55119-4227
Mailing Address - Country:US
Mailing Address - Phone:317-607-2121
Mailing Address - Fax:
Practice Address - Street 1:1205 GRAND AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55105-2634
Practice Address - Country:US
Practice Address - Phone:317-607-2121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-21
Last Update Date:2025-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3313101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health