Provider Demographics
NPI:1427863521
Name:CLARK, JACKSON LEE
Entity type:Individual
Prefix:
First Name:JACKSON
Middle Name:LEE
Last Name:CLARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:990 KLAMATH LN STE 9
Mailing Address - Street 2:
Mailing Address - City:YUBA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95993-8978
Mailing Address - Country:US
Mailing Address - Phone:916-729-3098
Mailing Address - Fax:
Practice Address - Street 1:635 W 2ND AVE APT 8
Practice Address - Street 2:
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95926-8027
Practice Address - Country:US
Practice Address - Phone:415-521-8018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-07
Last Update Date:2025-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician