=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962291906
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CLARK JOHNSON ENTERPRISES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/05/2025
-----------------------------------------------------
Last Update Date | 09/24/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7333 E LIVINGSTON AVE STE A
-----------------------------------------------------
City | REYNOLDSBURG
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43068-3098
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-200-8445
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 29044
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43229-0044
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-200-8445
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | TAKARA CLARK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 513-227-6941
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251K00000X
-----------------------------------------------------
Taxonomy Name | Public Health or Welfare Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 385H00000X
-----------------------------------------------------
Taxonomy Name | Respite Care
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------