Provider Demographics
NPI:1336118454
Name:CLARK, JON B (PHD)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:B
Last Name:CLARK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71 WALNUT BLVD
Mailing Address - Street 2:SUITE 109
Mailing Address - City:ROCHESTER
Mailing Address - State:MI
Mailing Address - Zip Code:48307-2073
Mailing Address - Country:US
Mailing Address - Phone:248-650-8990
Mailing Address - Fax:248-650-8990
Practice Address - Street 1:71 WALNUT BLVD
Practice Address - Street 2:SUITE 109
Practice Address - City:ROCHESTER
Practice Address - State:MI
Practice Address - Zip Code:48307-2073
Practice Address - Country:US
Practice Address - Phone:248-650-8990
Practice Address - Fax:248-650-8990
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-14
Last Update Date:2016-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301005160103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
R67275Medicare UPIN
0F349203681Medicare ID - Type Unspecified