Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YP2500X | Professional Counselor | 2009017630 | MO |
NPI | 1003185497 |
---|---|
Provider Name | Janna L. Clark Roselius |
First Address | Saint James, MO 65559-8879 |
Second Address | Saint James, MO 65559-8879 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 14/12/2011 |
Last Update Date | 14/12/2011 |