Provider Demographics
NPI:1124690334
Name:CLARK, JERONIA
Entity type:Individual
Prefix:
First Name:JERONIA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 N JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:STARKVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39759-2504
Mailing Address - Country:US
Mailing Address - Phone:166-252-4434
Mailing Address - Fax:
Practice Address - Street 1:1001 MAIN ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39701-4751
Practice Address - Country:US
Practice Address - Phone:662-328-9225
Practice Address - Fax:662-328-4735
Is Sole Proprietor?:No
Enumeration Date:2021-07-15
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1124690334Medicaid