Provider Demographics
NPI:1548452956
Name:CLARK, JACQUELINE RENEE (BA, HRC)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:RENEE
Last Name:CLARK
Suffix:
Gender:F
Credentials:BA, HRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17964 COUNTY ROAD 1500
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-4717
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:118 E MAIN ST
Practice Address - Street 2:
Practice Address - City:HOLDENVILLE
Practice Address - State:OK
Practice Address - Zip Code:74848-3208
Practice Address - Country:US
Practice Address - Phone:405-379-5256
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-10
Last Update Date:2007-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor