Provider Demographics
NPI:1861777096
Name:CLARK, JILL B (LMSW)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:B
Last Name:CLARK
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5123 OLD PLANK RD
Mailing Address - Street 2:
Mailing Address - City:ONONDAGA
Mailing Address - State:MI
Mailing Address - Zip Code:49264-9707
Mailing Address - Country:US
Mailing Address - Phone:517-628-2287
Mailing Address - Fax:517-628-3421
Practice Address - Street 1:5123 OLD PLANK RD
Practice Address - Street 2:
Practice Address - City:ONONDAGA
Practice Address - State:MI
Practice Address - Zip Code:49264-9707
Practice Address - Country:US
Practice Address - Phone:517-628-2287
Practice Address - Fax:517-628-3421
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-19
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801078236101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health