Provider Demographics
NPI:1477799112
Name:CLARK, JACK
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:830 WEST AVE
Mailing Address - Street 2:
Mailing Address - City:SANGER
Mailing Address - State:CA
Mailing Address - Zip Code:93657-2849
Mailing Address - Country:US
Mailing Address - Phone:559-248-1548
Mailing Address - Fax:559-248-1530
Practice Address - Street 1:4411 N CEDAR AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93726-2538
Practice Address - Country:US
Practice Address - Phone:559-248-1548
Practice Address - Fax:229-248-1530
Is Sole Proprietor?:No
Enumeration Date:2008-12-31
Last Update Date:2008-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)