Provider Demographics
NPI:1730517087
Name:CLARK, JESSE WAYNE (LPCC)
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:WAYNE
Last Name:CLARK
Suffix:
Gender:M
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5400 EDALBERT DR
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45239-7604
Mailing Address - Country:US
Mailing Address - Phone:937-416-4031
Mailing Address - Fax:937-534-1347
Practice Address - Street 1:65 GRADY CT
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45409
Practice Address - Country:US
Practice Address - Phone:937-416-4031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-24
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.1200356101YM0800X
OHE.1600066101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health