Provider Demographics
NPI:1184335820
Name:CLARK, JESSICA LYNN (MA/CAGS)
Entity type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:LYNN
Last Name:CLARK
Suffix:
Gender:F
Credentials:MA/CAGS
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:LYNN
Other - Last Name:VITTORINO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA/CAGS
Mailing Address - Street 1:1190 SW JERICHO AVE
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-6889
Mailing Address - Country:US
Mailing Address - Phone:772-259-0474
Mailing Address - Fax:
Practice Address - Street 1:1190 SW JERICHO AVE
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-6889
Practice Address - Country:US
Practice Address - Phone:772-259-0474
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-13
Last Update Date:2022-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSS1724103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool