Healthcare Provider Details

I. General information

NPI: 1316866940
Provider Name (Legal Business Name): JESSICA CLARK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2026
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 SURREY CT
WESTMINSTER MD
21157-6528
US

IV. Provider business mailing address

1004 LITTLESTOWN PIKE STE C
WESTMINSTER MD
21157-3027
US

V. Phone/Fax

Practice location:
  • Phone: 410-596-9821
  • Fax:
Mailing address:
  • Phone: 717-465-0943
  • Fax: 443-952-2710

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLGA3450
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: