Provider Demographics
NPI:1992088611
Name:CLARK, JENNIFER K (PHD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:K
Last Name:CLARK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43130 AMBERWOOD PLZ
Mailing Address - Street 2:SUITE 140
Mailing Address - City:SOUTH RIDING
Mailing Address - State:VA
Mailing Address - Zip Code:20152-4105
Mailing Address - Country:US
Mailing Address - Phone:703-542-7770
Mailing Address - Fax:
Practice Address - Street 1:43130 AMBERWOOD PLZ
Practice Address - Street 2:SUITE 140
Practice Address - City:SOUTH RIDING
Practice Address - State:VA
Practice Address - Zip Code:20152-4105
Practice Address - Country:US
Practice Address - Phone:703-542-7770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-20
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810004270103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical