Provider Demographics
NPI:1912049594
Name:CLARK, ALETHA JENNIFER (PHD, LPC)
Entity type:Individual
Prefix:MS
First Name:ALETHA
Middle Name:JENNIFER
Last Name:CLARK
Suffix:
Gender:F
Credentials:PHD, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 955
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-0955
Mailing Address - Country:US
Mailing Address - Phone:404-550-0564
Mailing Address - Fax:678-344-2956
Practice Address - Street 1:2386 CLOWER ST STE D-100
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-6134
Practice Address - Country:US
Practice Address - Phone:404-550-0564
Practice Address - Fax:678-344-2956
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1658-R101YA0400X
GALPC004805101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA894502453AMedicaid