Provider Demographics
NPI:1093387664
Name:CLARK, JESSICA LANE (DNP, PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LANE
Last Name:CLARK
Suffix:
Gender:F
Credentials:DNP, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:695 KINGS RD
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-3119
Mailing Address - Country:US
Mailing Address - Phone:706-247-6029
Mailing Address - Fax:
Practice Address - Street 1:695 KINGS RD
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-3119
Practice Address - Country:US
Practice Address - Phone:706-247-6029
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-13
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN222359363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty