Provider Demographics
NPI:1952945248
Name:CLARK, JEFFREY KENNETH
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:KENNETH
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 1:2350 WOODHILL DR
Mailing Address - Street 2:
Mailing Address - City:PITTSBURG
Mailing Address - State:CA
Mailing Address - Zip Code:94565-7332
Mailing Address - Country:US
Mailing Address - Phone:510-589-2106
Mailing Address - Fax:
Practice Address - Street 1:1470 CIVIC CT
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-5290
Practice Address - Country:US
Practice Address - Phone:925-849-6173
Practice Address - Fax:925-849-6832
Is Sole Proprietor?:No
Enumeration Date:2019-10-30
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)