Provider Demographics
NPI:1497232060
Name:CLARK, JERRY DEAN (SUDR, CPC, AAC)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:DEAN
Last Name:CLARK
Suffix:
Gender:M
Credentials:SUDR, CPC, AAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2394
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632
Mailing Address - Country:US
Mailing Address - Phone:360-200-5419
Mailing Address - Fax:360-200-6736
Practice Address - Street 1:1616 S GOLD ST STE 4
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-8930
Practice Address - Country:US
Practice Address - Phone:360-807-4929
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-25
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60783169175T00000X
WA175T00000X, 175T00000X
WACP61099597101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer Specialist