Provider Demographics
NPI:1326412784
Name:CLARK, JOHN A (MASTER DEGREE)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:CLARK
Suffix:
Gender:M
Credentials:MASTER DEGREE
Other - Prefix:
Other - First Name:JOHN
Other - Middle Name:A
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MASTER DEGREE
Mailing Address - Street 1:2439 MANHATTAN BLVD STE 402
Mailing Address - Street 2:
Mailing Address - City:HARVEY
Mailing Address - State:LA
Mailing Address - Zip Code:70058-5469
Mailing Address - Country:US
Mailing Address - Phone:504-304-4097
Mailing Address - Fax:540-218-7986
Practice Address - Street 1:2439 MANHATTAN BLVD STE 402
Practice Address - Street 2:
Practice Address - City:HARVEY
Practice Address - State:LA
Practice Address - Zip Code:70058-5469
Practice Address - Country:US
Practice Address - Phone:504-304-4097
Practice Address - Fax:540-218-7986
Is Sole Proprietor?:No
Enumeration Date:2015-11-23
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA800735847Medicaid