1962508192 NPI number — MR. CLARK KENT JACKSON MSW

Table of content: MR. CLARK KENT JACKSON MSW (NPI 1962508192)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962508192 NPI number — MR. CLARK KENT JACKSON MSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACKSON
Provider First Name:
CLARK
Provider Middle Name:
KENT
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MSW
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1962508192
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2004 E 1ST AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELLENSBURG
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98926-9021
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-933-4803
Provider Business Mailing Address Fax Number:
509-962-2286

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6 S 2ND ST
Provider Second Line Business Practice Location Address:
STE 918
Provider Business Practice Location Address City Name:
YAKIMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98901-2632
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-961-8233
Provider Business Practice Location Address Fax Number:
509-962-2286
Provider Enumeration Date:
09/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  LW6908 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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