Provider Demographics
NPI:1427019926
Name:CLARK, JANET LEE (PHD)
Entity Type:Individual
Prefix:DR
First Name:JANET
Middle Name:LEE
Last Name:CLARK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5801 THOMPSON RD
Mailing Address - Street 2:
Mailing Address - City:GAHANNA
Mailing Address - State:OH
Mailing Address - Zip Code:43230-1349
Mailing Address - Country:US
Mailing Address - Phone:614-855-1170
Mailing Address - Fax:614-855-1170
Practice Address - Street 1:3449 E LIVINGSTON AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43227-2220
Practice Address - Country:US
Practice Address - Phone:614-231-7255
Practice Address - Fax:614-855-1170
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-01
Last Update Date:2007-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3908103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCLCP05573Medicare PIN
OHCLCP05572Medicare PIN