Healthcare Provider Details

I. General information

NPI: 1952992133
Provider Name (Legal Business Name): MR. JAYCE DEAN CLARK II
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2021
Last Update Date: 08/04/2025
Certification Date: 08/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1053 W 1020 S
PROVO UT
84601-5656
US

IV. Provider business mailing address

141 S 200 W
AMERICAN FORK UT
84003-2207
US

V. Phone/Fax

Practice location:
  • Phone: 801-515-3323
  • Fax:
Mailing address:
  • Phone: 808-391-0052
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number14197389-6006
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: