Provider Demographics
NPI:1750194643
Name:CLARK, JACOB
Entity type:Individual
Prefix:
First Name:JACOB
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 1:100 MALTON RD
Mailing Address - Street 2:
Mailing Address - City:NEGAUNEE
Mailing Address - State:MI
Mailing Address - Zip Code:49866-2001
Mailing Address - Country:US
Mailing Address - Phone:906-228-9699
Mailing Address - Fax:
Practice Address - Street 1:1416 W EASTERDAY AVE
Practice Address - Street 2:
Practice Address - City:SAULT SAINTE MARIE
Practice Address - State:MI
Practice Address - Zip Code:49783-1415
Practice Address - Country:US
Practice Address - Phone:906-632-9809
Practice Address - Fax:906-632-9845
Is Sole Proprietor?:No
Enumeration Date:2025-01-27
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)