Provider Demographics
NPI:1841311487
Name:CLARK, JACK MALCOLM III (LCSW)
Entity type:Individual
Prefix:MR
First Name:JACK
Middle Name:MALCOLM
Last Name:CLARK
Suffix:III
Gender:M
Credentials:LCSW
Other - Prefix:
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Mailing Address - Street 1:BROOKE ARMY MEDICAL CENTER
Mailing Address - Street 2:
Mailing Address - City:FT. SAM HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:78234-4504
Mailing Address - Country:US
Mailing Address - Phone:210-916-3704
Mailing Address - Fax:210-916-8410
Practice Address - Street 1:7711 MADONNA
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78216-6620
Practice Address - Country:US
Practice Address - Phone:210-377-1133
Practice Address - Fax:210-377-1230
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX361511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX87614QOtherCLARK BCBS
TX175693402Medicaid
TX87614QOtherCLARK BCBS