Provider Demographics
NPI:1972128148
Name:CLARK, JEFF
Entity Type:Individual
Prefix:
First Name:JEFF
Middle Name:
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 1:208 CARTER ST
Mailing Address - Street 2:
Mailing Address - City:MUNFORD
Mailing Address - State:AL
Mailing Address - Zip Code:36268-6984
Mailing Address - Country:US
Mailing Address - Phone:256-521-1666
Mailing Address - Fax:
Practice Address - Street 1:118 E CHOCCOLOCCO ST
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:AL
Practice Address - Zip Code:36203-1222
Practice Address - Country:US
Practice Address - Phone:256-831-4601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-12
Last Update Date:2020-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)