Provider Demographics
NPI:1063403822
Name:CLARK, JEFFREY P (PSYD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:P
Last Name:CLARK
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1969 S SHERIDAN AVE
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-6108
Mailing Address - Country:US
Mailing Address - Phone:307-672-7481
Mailing Address - Fax:307-674-5117
Practice Address - Street 1:339 W LOUCKS ST
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-4121
Practice Address - Country:US
Practice Address - Phone:307-674-4462
Practice Address - Fax:307-674-4552
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY409103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical