Provider Demographics
NPI:1174840789
Name:CLARK, JEFFRY RUSSELL (MFC)
Entity Type:Individual
Prefix:DR
First Name:JEFFRY
Middle Name:RUSSELL
Last Name:CLARK
Suffix:
Gender:M
Credentials:MFC
Other - Prefix:DR
Other - First Name:JEFFRY
Other - Middle Name:RUSSELL
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:220 S. CALIFORNIA AVE., SUITE 206
Mailing Address - Street 2:
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94306
Mailing Address - Country:US
Mailing Address - Phone:650-322-4944
Mailing Address - Fax:650-322-4944
Practice Address - Street 1:220 S CALIFORNIA AVE STE 206
Practice Address - Street 2:
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94306-1636
Practice Address - Country:US
Practice Address - Phone:650-322-4944
Practice Address - Fax:650-322-4944
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-23
Last Update Date:2010-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT 18251101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health