Provider Demographics
NPI:1679508345
Name:CLARK, JORDAN BARTON (MS, CCC-SLP)
Entity Type:Individual
Prefix:MR
First Name:JORDAN
Middle Name:BARTON
Last Name:CLARK
Suffix:
Gender:M
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1462 S 231ST LN
Mailing Address - Street 2:
Mailing Address - City:BUCKEYE
Mailing Address - State:AZ
Mailing Address - Zip Code:85326-6131
Mailing Address - Country:US
Mailing Address - Phone:623-327-0931
Mailing Address - Fax:
Practice Address - Street 1:1462 S 231ST LN
Practice Address - Street 2:
Practice Address - City:BUCKEYE
Practice Address - State:AZ
Practice Address - Zip Code:85326-6131
Practice Address - Country:US
Practice Address - Phone:623-327-0931
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP1347235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ644535Medicaid