Individual
JESSICA CLARK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
42189 SHADOW CREEK AVE, GONZALES, LA 70737-7241
(225) 978-7583
Mailing address
42189 SHADOW CREEK AVE, GONZALES, LA 70737-7241
(225) 978-7583
Taxonomy
Speciality
Code
Description
License number
State
101Y00000X
Counselor
Primary
—
—
171M00000X
Case Manager/Care Coordinator
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0000
—
LA
Enumeration date
09/19/2017
Last updated
07/21/2022
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