Provider Demographics
NPI:1790505154
Name:CLARK, JAMES ROBERT
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:ROBERT
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 1:14500 ROSCOE BLVD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:PANORAMA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91402
Mailing Address - Country:US
Mailing Address - Phone:818-741-2906
Mailing Address - Fax:
Practice Address - Street 1:14500 ROSCOE BLVD
Practice Address - Street 2:SUITE 400
Practice Address - City:PANORAMA CITY
Practice Address - State:CA
Practice Address - Zip Code:91402
Practice Address - Country:US
Practice Address - Phone:818-741-2906
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-11
Last Update Date:2024-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker