Provider Demographics
NPI:1154610269
Name:CLARK, JESSICA (LICSW)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 FLOYD AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:RI
Mailing Address - Zip Code:02915-2927
Mailing Address - Country:US
Mailing Address - Phone:401-743-5313
Mailing Address - Fax:
Practice Address - Street 1:55 FLOYD AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:RI
Practice Address - Zip Code:02915-2927
Practice Address - Country:US
Practice Address - Phone:401-743-5313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-30
Last Update Date:2013-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW023371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical