Healthcare Provider Details

I. General information

NPI: 1245953199
Provider Name (Legal Business Name): JENNIFER ANNE CLARK LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2022
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

183 WILDWOOD CT
RICHLAND WA
99352-9499
US

IV. Provider business mailing address

183 WILDWOOD CT
RICHLAND WA
99352-9499
US

V. Phone/Fax

Practice location:
  • Phone: 509-779-8604
  • Fax:
Mailing address:
  • Phone: 509-779-8604
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMHC.LH.61691556
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180.016757
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: