Provider Demographics
NPI:1164120150
Name:CROCKETT, CLAY JUSTIN (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:CLAY
Middle Name:JUSTIN
Last Name:CROCKETT
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1820 N 202ND AVE
Mailing Address - Street 2:
Mailing Address - City:BUCKEYE
Mailing Address - State:AZ
Mailing Address - Zip Code:85396-8712
Mailing Address - Country:US
Mailing Address - Phone:602-820-3201
Mailing Address - Fax:
Practice Address - Street 1:1820 N 202ND AVE
Practice Address - Street 2:
Practice Address - City:BUCKEYE
Practice Address - State:AZ
Practice Address - Zip Code:85396-8712
Practice Address - Country:US
Practice Address - Phone:602-820-3201
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-20
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN197246163WP0808X
AZ294847363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ138626Medicaid