Provider Demographics
NPI:1457614885
Name:CLARK, ROBERT JON JR (MA, LPC)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:JON
Last Name:CLARK
Suffix:JR
Gender:M
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4514 COLE AVE
Mailing Address - Street 2:SUITE 600
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75205-5412
Mailing Address - Country:US
Mailing Address - Phone:214-907-0089
Mailing Address - Fax:
Practice Address - Street 1:4514 COLE AVE
Practice Address - Street 2:SUITE 600
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75205-5412
Practice Address - Country:US
Practice Address - Phone:214-907-0089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-20
Last Update Date:2016-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX66476101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX309292601Medicaid
TX309292602Medicaid
TX8380LCOtherBLUE CROSS BLUE SHIELD