Healthcare Provider Details

I. General information

NPI: 1972125821
Provider Name (Legal Business Name): JENESIS E CLARK LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2020
Last Update Date: 03/20/2024
Certification Date: 03/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 BURNET AVE ML 3015
CINCINNATI OH
45229
US

IV. Provider business mailing address

5556 CLEARVIEW AVE
CINCINNATI OH
45248-3216
US

V. Phone/Fax

Practice location:
  • Phone: 513-636-4336
  • Fax: 513-636-7756
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberE.2404016
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberE.2404016
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: