Provider Demographics
NPI:1891354791
Name:CLAYTON, JAMES
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:CLAYTON
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 1:1611 E 32ND ST
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1828
Mailing Address - Country:US
Mailing Address - Phone:651-795-9256
Mailing Address - Fax:
Practice Address - Street 1:1611 E 32ND ST
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-1828
Practice Address - Country:US
Practice Address - Phone:651-795-9256
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-13
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
1245879OtherSHYNE BRIGHT SERVICES
MN47551326Medicaid