Jerry Dean Clark, SUDP, CPSS

Primary specialty

Addiction (Substance Use Disorder) CounselorTaxonomy code 101YA0400X

License

CP61099597 Issued in WA

Practice address

1126 S Gold St
Centralia, WA 98531-3714

Phone

(360) 827-4929

Fax

(844) 612-6673

NPI assigned

Jul 25, 2018

Last updated

Aug 31, 2026By the provider in NPPES

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Community Integrated Health Services, LLC

  • Community/Behavioral Health Agency
  • Centralia, WA
  • NPI 1942840160

  Addiction (Substance Use Disorder)

  NPD (past)
• Core Health

  • Mental Health Clinic/Center (Including Community Mental Health Center)
  • Longview, WA
  • NPI 1639693781
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1532476800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1788134400000",
    "number": "1497232060",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 2394",
            "city": "LONGVIEW",
            "state": "WA",
            "postal_code": "986328455",
            "telephone_number": "360-200-5419",
            "fax_number": "360-200-6736"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1126 S GOLD ST",
            "city": "CENTRALIA",
            "state": "WA",
            "postal_code": "985313714",
            "telephone_number": "360-827-4929",
            "fax_number": "844-612-6673"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "CLARK",
        "first_name": "JERRY",
        "middle_name": "DEAN",
        "credential": "SUDP, CPSS",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2018-07-25",
        "last_updated": "2026-08-31",
        "certification_date": "2026-08-31",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "101YA0400X",
            "taxonomy_group": "",
            "desc": "Counselor, Addiction (Substance Use Disorder)",
            "state": "WA",
            "license": "CP61099597",
            "primary": true
        },
        {
            "code": "175T00000X",
            "taxonomy_group": "",
            "desc": "Peer Specialist",
            "state": "WA",
            "license": "PR70101410",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "2140419",
            "state": "WA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Silvia Vianney Cisneros Campos, INTERPRETER
• Kaila R Cisneros Sanchez
• Miguel Cisneros Sanchez
• Allison Clark, LMP
• David Nicholas Clark, PT,DPT
• Shonna Clark, AAC
• Regine Claude
• Richard Emery Clevenger Jr., BA,AAC
• Ryan Coleman, CPSST
• Community Integrated Health Services, LLC

• Addiction (Substance Use Disorder) Counselor in Centralia, WA
• Providers in Centralia, WA by specialty
• Addiction (Substance Use Disorder) Counselor in Washington

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 31, 2026; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.