Provider Demographics
NPI:1326407206
Name:CLARK, JEANNETTE B (MSED, LPCC)
Entity type:Individual
Prefix:
First Name:JEANNETTE
Middle Name:B
Last Name:CLARK
Suffix:
Gender:F
Credentials:MSED, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 279
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:OH
Mailing Address - Zip Code:43080-0279
Mailing Address - Country:US
Mailing Address - Phone:740-759-1490
Mailing Address - Fax:
Practice Address - Street 1:941 RIVER RD
Practice Address - Street 2:
Practice Address - City:GRANVILLE
Practice Address - State:OH
Practice Address - Zip Code:43023-9534
Practice Address - Country:US
Practice Address - Phone:740-587-1543
Practice Address - Fax:740-587-1573
Is Sole Proprietor?:No
Enumeration Date:2016-02-19
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.2001704101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1473276Medicaid