Provider Demographics
NPI:1285758094
Name:CLARK, JAMES ROBERT (PSYD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:ROBERT
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 1:125 EXECUTIVE DR
Mailing Address - Street 2:SUITE 106
Mailing Address - City:MARION
Mailing Address - State:OH
Mailing Address - Zip Code:43302
Mailing Address - Country:US
Mailing Address - Phone:740-382-5133
Mailing Address - Fax:740-383-2289
Practice Address - Street 1:125 EXECUTIVE DR
Practice Address - Street 2:SUITE 106
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43302
Practice Address - Country:US
Practice Address - Phone:740-382-5133
Practice Address - Fax:740-383-2289
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2009-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4571103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND000000333769OtherANTHEM
OH4535225OtherAETNA
OH4535225OtherAETNA