Provider Demographics
NPI:1598198954
Name:CLARK, JAYSON (MSMFT, LPC)
Entity Type:Individual
Prefix:
First Name:JAYSON
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:MSMFT, LPC
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 1121
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-0254
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:621 W MADRONE ST
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470
Practice Address - Country:US
Practice Address - Phone:541-672-2691
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-20
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT-17-081101YA0400X
101YM0800X
ORC5596101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500725582Medicaid
OR500714629Medicaid