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General NPI Number Information
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NPI Number | 1750678108
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Entity Type | Organization
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Legal Business Name | JERRY W CLARK, PHD, LTD.
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Dates
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Enumeration Date | 07/06/2011
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Last Update Date | 07/13/2011
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Provider Practice Location Address
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Address Line | 200 SO. VIRGINIA ST. 8TH FLOOR
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City | RENO
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State | NV
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Zip | 89501-2405
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Country | US
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Telephone | 775-772-0392
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Fax | 775-772-0392
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Provider Business Mailing Address
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Address Line | P. O. BOX 14223
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City | RENO
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State | NV
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Zip | 89507-4223
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Country | US
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Telephone | 775-772-0392
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Fax | 775-972-6377
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Authorized Official
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Title or Position | OWNER
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Name | DR. JERRY W CLARK
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Credential | PH.D.
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Telephone | 775-772-0392
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 00004-C
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License Number State | NV
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