Provider Demographics
NPI:1750656708
Name:CLARK, JEREMIAH FRANK (MS CCC-SLP)
Entity Type:Individual
Prefix:MR
First Name:JEREMIAH
Middle Name:FRANK
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 1:74 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:CRESWELL
Mailing Address - State:OR
Mailing Address - Zip Code:97426-9649
Mailing Address - Country:US
Mailing Address - Phone:541-221-1262
Mailing Address - Fax:
Practice Address - Street 1:74 N 3RD ST
Practice Address - Street 2:
Practice Address - City:CRESWELL
Practice Address - State:OR
Practice Address - Zip Code:97426-9649
Practice Address - Country:US
Practice Address - Phone:541-221-1262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-08
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR13589235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist