Provider Demographics
NPI:1982198610
Name:CLARK, JESSICA (DNP, PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:DNP, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 ATCHESON ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43203-1353
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 ATCHESON ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43203-1353
Practice Address - Country:US
Practice Address - Phone:614-252-4941
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-16
Last Update Date:2024-01-08
Deactivation Date:2020-09-02
Deactivation Code:
Reactivation Date:2020-09-23
Provider Licenses
StateLicense IDTaxonomies
OHRN.438874163WP0807X
OHAPRN.CNP.0027330363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1962855452Medicaid