Healthcare Provider Details

I. General information

NPI: 1962054387
Provider Name (Legal Business Name): JESSICA LYNN CLARK DNP, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2019
Last Update Date: 09/13/2025
Certification Date: 09/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3780 N BUFFALO ST STE 8
ORCHARD PARK NY
14127-1855
US

IV. Provider business mailing address

3780 N BUFFALO ST STE 8
ORCHARD PARK NY
14127-1855
US

V. Phone/Fax

Practice location:
  • Phone: 716-210-6230
  • Fax: 716-272-9263
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number402755
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number402755
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: