Provider Demographics
NPI:1194093237
Name:CLARK, JENNIFER REBECCA (MS SLP INTERN)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:REBECCA
Last Name:CLARK
Suffix:
Gender:F
Credentials:MS SLP INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7518 MEADOW OAKS DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230-4851
Mailing Address - Country:US
Mailing Address - Phone:214-903-0996
Mailing Address - Fax:
Practice Address - Street 1:7518 MEADOW OAKS DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230-4851
Practice Address - Country:US
Practice Address - Phone:214-903-0996
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-04
Last Update Date:2011-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX107126235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist