Provider Demographics
NPI:1831308428
Name:CLARK, TAJ JAMAL (LCDC)
Entity Type:Individual
Prefix:MR
First Name:TAJ
Middle Name:JAMAL
Last Name:CLARK
Suffix:
Gender:M
Credentials:LCDC
Other - Prefix:MR
Other - First Name:TAJ
Other - Middle Name:JAMAL
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCDC
Mailing Address - Street 1:3130 STRAWBERRY RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:PASADENA
Mailing Address - State:TX
Mailing Address - Zip Code:77504-1767
Mailing Address - Country:US
Mailing Address - Phone:832-984-1868
Mailing Address - Fax:
Practice Address - Street 1:3130 STRAWBERRY RD
Practice Address - Street 2:SUITE C
Practice Address - City:PASADENA
Practice Address - State:TX
Practice Address - Zip Code:77504-1767
Practice Address - Country:US
Practice Address - Phone:832-984-1868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2011-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9946101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)