Provider Demographics
NPI:1710058284
Name:CLARK, JERRY D (LPC)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:D
Last Name:CLARK
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1830 NASA PKWY STE 104
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77058-3544
Mailing Address - Country:US
Mailing Address - Phone:281-335-8422
Mailing Address - Fax:281-335-0702
Practice Address - Street 1:1830 NASA PKWY STE 104
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77058-3544
Practice Address - Country:US
Practice Address - Phone:281-335-8422
Practice Address - Fax:281-335-0702
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15162101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health