Provider Demographics
NPI:1275785651
Name:CLARK, JESSICA ASHLEY (MA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ASHLEY
Last Name:CLARK
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:ASHLEY
Other - Last Name:HOOPER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:402 15TH AVE SE
Mailing Address - Street 2:#100
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98372-3709
Mailing Address - Country:US
Mailing Address - Phone:253-697-5200
Mailing Address - Fax:253-697-5248
Practice Address - Street 1:402 15TH AVE SE
Practice Address - Street 2:#100
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-3709
Practice Address - Country:US
Practice Address - Phone:253-697-5200
Practice Address - Fax:253-697-5248
Is Sole Proprietor?:No
Enumeration Date:2008-10-16
Last Update Date:2008-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL60024411235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist