Provider Demographics
NPI:1750678108
Name:JERRY W CLARK, PHD, LTD.
Entity Type:Organization
Organization Name:JERRY W CLARK, PHD, LTD.
Other - Org Name:BEHAVIORAL SERVICES LTD
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:W
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:775-772-0392
Mailing Address - Street 1:P. O. BOX 14223
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89507-4223
Mailing Address - Country:US
Mailing Address - Phone:775-772-0392
Mailing Address - Fax:775-972-6377
Practice Address - Street 1:200 SO. VIRGINIA ST.
Practice Address - Street 2:8TH FLOOR
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89501-2405
Practice Address - Country:US
Practice Address - Phone:775-772-0392
Practice Address - Fax:775-772-0392
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-06
Last Update Date:2011-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV00004-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1245454628Medicaid
NV1245454628Medicaid