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General NPI Number Information
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NPI Number | 1518685965
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Entity Type | Individual
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Provider Name | JASON J CLARK CPC
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Gender | Male
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Dates
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Enumeration Date | 08/19/2022
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Last Update Date | 08/19/2022
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Provider Practice Location Address
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Address Line | 500 S 336TH ST STE 102
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City | FEDERAL WAY
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State | WA
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Zip | 98003-6389
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Country | US
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Telephone | 206-261-2410
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Fax |
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Provider Business Mailing Address
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Address Line | 3812 LANYARD DR NE
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City | LACEY
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State | WA
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Zip | 98516-1333
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Country | US
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Telephone | 206-261-2410
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 175T00000X
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Taxonomy Name | Peer Specialist
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License Number |
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License Number State |
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