Individual
JERRY DEAN CLARK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
SUDR, CPC, AAC
Contact information
Practice address
1616 S GOLD ST STE 4, CENTRALIA, WA 98531-8930
(360) 807-4929
Mailing address
PO BOX 2394, LONGVIEW, WA 98632
(360) 200-5419
(360) 200-6736
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
CP61099597
WA
175T00000X
Peer Specialist
CG60783169
WA
175T00000X
Peer Specialist
—
WA
Other
Enumeration date
07/25/2018
Last updated
11/13/2020
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