Provider Demographics
NPI:1811301617
Name:CLARK, JOHN (LSW)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3791 E DEER CRK
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-6804
Mailing Address - Country:US
Mailing Address - Phone:208-403-1327
Mailing Address - Fax:
Practice Address - Street 1:540 3RD ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-3953
Practice Address - Country:US
Practice Address - Phone:208-524-5607
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-19
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLSW1381104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker