Individual
JAYSON CLARK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MSMFT, LPC
Contact information
Practice address
621 W MADRONE ST, ROSEBURG, OR 97470
(541) 672-2691
Mailing address
PO BOX 1121, ROSEBURG, OR 97470-0254
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
T-17-081
OR
101YM0800X
Mental Health Counselor
—
—
101YP2500X
Professional Counselor
Primary
C5596
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
500714629
—
OR
05
—
500725582
—
OR
Enumeration date
08/20/2013
Last updated
07/07/2022
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