Provider Demographics
NPI:1831834332
Name:CLARK, JAYLESSE SHABRI
Entity type:Individual
Prefix:
First Name:JAYLESSE
Middle Name:SHABRI
Last Name:CLARK
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 1:16379 E PRESERVE LOOP UNIT 2150
Mailing Address - Street 2:
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91708-9408
Mailing Address - Country:US
Mailing Address - Phone:725-724-6914
Mailing Address - Fax:
Practice Address - Street 1:16379 E PRESERVE LOOP UNIT 2150
Practice Address - Street 2:
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91708-9408
Practice Address - Country:US
Practice Address - Phone:725-724-6914
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-29
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAY3408986103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst