Provider Demographics
NPI:1104699586
Name:CLARK, JASON MATTHEW (LICSW)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:MATTHEW
Last Name:CLARK
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9869 PULASKI PIKE STE C
Mailing Address - Street 2:
Mailing Address - City:TONEY
Mailing Address - State:AL
Mailing Address - Zip Code:35773-7201
Mailing Address - Country:US
Mailing Address - Phone:256-850-4091
Mailing Address - Fax:256-975-1643
Practice Address - Street 1:9869 PULASKI PIKE STE C
Practice Address - Street 2:
Practice Address - City:TONEY
Practice Address - State:AL
Practice Address - Zip Code:35773-7201
Practice Address - Country:US
Practice Address - Phone:256-850-4091
Practice Address - Fax:256-970-1643
Is Sole Proprietor?:No
Enumeration Date:2023-11-06
Last Update Date:2025-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL5478C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical