MEDICARE: JEFFREY SCOTT CLARK LMHC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	LH61052282	WA

General Provider Information

NPI Number	:	1619505914
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEFFREY SCOTT CLARK LMHC

Provider Business Mailing Address
First Line	:	402 E YAKIMA AVE STE 800
Second Line	:
City	:	YAKIMA
State	:	WA
Zip	:	98901-5410
Country	:	US
Telephone Number	:	509-833-7528
Fax Number	:	509-457-2756

Provider Business Practice Location Address
First Line	:	402 E YAKIMA AVE STE 800-C
Second Line	:
City	:	YAKIMA
State	:	WA
Zip	:	98901-5407
Country	:	US
Telephone Number	:	509-833-7528
Fax Number	:	509-457-2756

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/31/2020
Last Update Date	:	04/01/2020

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