Provider Demographics
NPI:1356958383
Name:CLARK, JEREMY KEITH
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:KEITH
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 1:566 E 500 N
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84321-4251
Mailing Address - Country:US
Mailing Address - Phone:453-938-8562
Mailing Address - Fax:
Practice Address - Street 1:1525 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84404-5638
Practice Address - Country:US
Practice Address - Phone:801-621-6510
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-24
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist