Provider Demographics
NPI:1801764972
Name:CLARK-WILBORN, JERICA
Entity type:Individual
Prefix:
First Name:JERICA
Middle Name:
Last Name:CLARK-WILBORN
Suffix:
Gender:F
Credentials:
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 14067
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30919-0067
Mailing Address - Country:US
Mailing Address - Phone:706-437-0505
Mailing Address - Fax:706-554-6219
Practice Address - Street 1:478 COLUMBIA INDUSTRIAL BLVD
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-6127
Practice Address - Country:US
Practice Address - Phone:706-437-0505
Practice Address - Fax:706-437-0505
Is Sole Proprietor?:No
Enumeration Date:2025-10-29
Last Update Date:2025-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-25-485968106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician