Provider Demographics
NPI:1982402871
Name:CLARK, SHAWNA P (CBHCMS, CMHP, HS-BCP)
Entity type:Individual
Prefix:
First Name:SHAWNA
Middle Name:P
Last Name:CLARK
Suffix:
Gender:
Credentials:CBHCMS, CMHP, HS-BCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 RIVERPLACE BLVD APT 811
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-9079
Mailing Address - Country:US
Mailing Address - Phone:912-278-0403
Mailing Address - Fax:
Practice Address - Street 1:2200 ROSSELLE ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-3126
Practice Address - Country:US
Practice Address - Phone:904-551-2399
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-05
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0102782171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator