Healthcare Provider Details

I. General information

NPI: 1982198610
Provider Name (Legal Business Name): JESSICA CLARK DNP, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2018
Last Update Date: 01/08/2024
Certification Date: 01/08/2024
Deactivation Date: 09/02/2020
Reactivation Date: 09/23/2020

III. Provider practice location address

1000 ATCHESON ST
COLUMBUS OH
43203-1353
US

IV. Provider business mailing address

1000 ATCHESON ST
COLUMBUS OH
43203-1353
US

V. Phone/Fax

Practice location:
  • Phone: 614-252-4941
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN.CNP.0027330
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License NumberRN.438874
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: