Provider Demographics
NPI:1962508192
Name:JACKSON, CLARK KENT (MSW)
Entity type:Individual
Prefix:MR
First Name:CLARK
Middle Name:KENT
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2004 E 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:ELLENSBURG
Mailing Address - State:WA
Mailing Address - Zip Code:98926-9021
Mailing Address - Country:US
Mailing Address - Phone:509-933-4803
Mailing Address - Fax:509-962-2286
Practice Address - Street 1:6 S 2ND ST
Practice Address - Street 2:STE 918
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98901-2632
Practice Address - Country:US
Practice Address - Phone:509-961-8233
Practice Address - Fax:509-962-2286
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW69081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical