Provider Demographics
NPI:1568684777
Name:CLARK, JILL (BA MS LPC)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:BA MS LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1210 BERNA LN
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-5554
Mailing Address - Country:US
Mailing Address - Phone:937-435-6623
Mailing Address - Fax:
Practice Address - Street 1:1170 E CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:WEST CARROLLTON
Practice Address - State:OH
Practice Address - Zip Code:45449-1825
Practice Address - Country:US
Practice Address - Phone:937-865-9061
Practice Address - Fax:937-865-9069
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC-5998101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor