MEDICARE: MR. JERRY D CLARK LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	15162	TX

General Provider Information

NPI Number	:	1710058284
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JERRY D CLARK LPC

Provider Business Mailing Address
First Line	:	1830 NASA PKWY STE 104
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77058-3544
Country	:	US
Telephone Number	:	281-335-8422
Fax Number	:	281-335-0702

Provider Business Practice Location Address
First Line	:	1830 NASA PKWY STE 104
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77058-3544
Country	:	US
Telephone Number	:	281-335-8422
Fax Number	:	281-335-0702

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/13/2006
Last Update Date	:	07/08/2007

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