Basic Information
| Provider Information | |||||||||
| NPI: | 1063140465 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 23614 EISENHOWER RD | ||||||||
| Address2: | |||||||||
| City: | NEWAYGO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 493379696 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6166176866 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 232 E 82ND ST | ||||||||
| Address2: | |||||||||
| City: | NEWAYGO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 493379631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2316521780 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2022 | ||||||||
| LastUpdateDate: | 08/12/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
ID Information
| ID | Type | State | Issuer | Description | NONE | 01 | MI | DO NOT HAVE IDENTIFIERS | OTHER |