Provider Demographics
NPI:1063855815
Name:CLARK, JAIME NICOLE (BCBA)
Entity Type:Individual
Prefix:
First Name:JAIME
Middle Name:NICOLE
Last Name:CLARK
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2603 E 137TH AVE
Mailing Address - Street 2:
Mailing Address - City:THORNTON
Mailing Address - State:CO
Mailing Address - Zip Code:80602
Mailing Address - Country:US
Mailing Address - Phone:303-570-0233
Mailing Address - Fax:
Practice Address - Street 1:2603 E 137TH AVE
Practice Address - Street 2:
Practice Address - City:THORNTON
Practice Address - State:CO
Practice Address - Zip Code:80602-7237
Practice Address - Country:US
Practice Address - Phone:303-570-0233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-11
Last Update Date:2013-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1-12-11853103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst