Provider Demographics
NPI:1124452537
Name:CLARK, JANE MARIE (LMSW)
Entity type:Individual
Prefix:
First Name:JANE
Middle Name:MARIE
Last Name:CLARK
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:JANE
Other - Middle Name:MARIE
Other - Last Name:SHELNUTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:1427 GENESEE ST
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13501-4343
Mailing Address - Country:US
Mailing Address - Phone:315-738-1428
Mailing Address - Fax:315-733-7105
Practice Address - Street 1:1427 GENESEE ST
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13501-4343
Practice Address - Country:US
Practice Address - Phone:315-738-1428
Practice Address - Fax:315-733-7105
Is Sole Proprietor?:No
Enumeration Date:2013-08-22
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY088842104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1215098207Medicaid