Provider Demographics
NPI:1720458615
Name:CLARKE, JONATHAN BLAKE (LCAS)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:BLAKE
Last Name:CLARKE
Suffix:
Gender:M
Credentials:LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1529 SHEPARD RD SE
Mailing Address - Street 2:
Mailing Address - City:SOUTHPORT
Mailing Address - State:NC
Mailing Address - Zip Code:28461-9435
Mailing Address - Country:US
Mailing Address - Phone:704-249-4231
Mailing Address - Fax:
Practice Address - Street 1:1529 SHEPARD RD SE
Practice Address - Street 2:
Practice Address - City:SOUTHPORT
Practice Address - State:NC
Practice Address - Zip Code:28461-9435
Practice Address - Country:US
Practice Address - Phone:704-249-4231
Practice Address - Fax:828-544-1201
Is Sole Proprietor?:No
Enumeration Date:2015-10-05
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-2729101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)