Provider Demographics
NPI:1790556322
Name:CLARK, ISAIAH JAMES
Entity Type:Individual
Prefix:
First Name:ISAIAH
Middle Name:JAMES
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 1:7889 TAMARACK DR
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:CA
Mailing Address - Zip Code:94568-1549
Mailing Address - Country:US
Mailing Address - Phone:925-623-2074
Mailing Address - Fax:
Practice Address - Street 1:5601 ARNOLD RD
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:CA
Practice Address - Zip Code:94568-7724
Practice Address - Country:US
Practice Address - Phone:925-462-2281
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-11
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician