Provider Demographics
NPI:1366184046
Name:CLARK, JODIE M (LSW)
Entity type:Individual
Prefix:
First Name:JODIE
Middle Name:M
Last Name:CLARK
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6782 E BRIARWOOD DR
Mailing Address - Street 2:
Mailing Address - City:CENTENNIAL
Mailing Address - State:CO
Mailing Address - Zip Code:80112-1156
Mailing Address - Country:US
Mailing Address - Phone:602-819-1842
Mailing Address - Fax:
Practice Address - Street 1:3895 UPHAM ST STE 100
Practice Address - Street 2:
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-4651
Practice Address - Country:US
Practice Address - Phone:303-500-5055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-12
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO8867075291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical