Provider Demographics
NPI:1245028075
Name:CLARK, JORDAN
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:CLARK
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12011 ENCHANTED CT
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22407-8579
Mailing Address - Country:US
Mailing Address - Phone:253-326-1045
Mailing Address - Fax:
Practice Address - Street 1:35 WALPOLE ST STE 207
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:VA
Practice Address - Zip Code:22554-6546
Practice Address - Country:US
Practice Address - Phone:540-383-7133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-30
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician