Provider Demographics
NPI:1225539570
Name:CLARK, JEFFERY DUANE (MSW, LICSW)
Entity type:Individual
Prefix:MR
First Name:JEFFERY
Middle Name:DUANE
Last Name:CLARK
Suffix:
Gender:M
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 HOSPITAL LOOP
Mailing Address - Street 2:
Mailing Address - City:FAIRCHILD AFB
Mailing Address - State:WA
Mailing Address - Zip Code:99011-8704
Mailing Address - Country:US
Mailing Address - Phone:509-953-0358
Mailing Address - Fax:
Practice Address - Street 1:701 HOSPITAL LOOP
Practice Address - Street 2:
Practice Address - City:FAIRCHILD AFB
Practice Address - State:WA
Practice Address - Zip Code:99011-8704
Practice Address - Country:US
Practice Address - Phone:509-953-0358
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-22
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW614351431041C0700X
WACP61031972101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)