Provider Demographics
NPI:1528426343
Name:DR JANE CLARK LLC
Entity type:Organization
Organization Name:DR JANE CLARK LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:APRN
Authorized Official - Prefix:DR
Authorized Official - First Name:JANE
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DNSC, MS
Authorized Official - Phone:860-490-0800
Mailing Address - Street 1:2 KEYSTONE CIR
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:CT
Mailing Address - Zip Code:06001-3312
Mailing Address - Country:US
Mailing Address - Phone:860-490-0800
Mailing Address - Fax:888-859-4374
Practice Address - Street 1:15 MEADOW ST
Practice Address - Street 2:
Practice Address - City:LITCHFIELD
Practice Address - State:CT
Practice Address - Zip Code:06759-3504
Practice Address - Country:US
Practice Address - Phone:860-490-0800
Practice Address - Fax:888-859-4374
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DR.JANE CLARK,APRN, DNSC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-02-08
Last Update Date:2016-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001952101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty