Individual
JACOB CLARK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
APRN, PMHNP-BC
Contact information
Practice address
138 E 12300 S UNIT 860, DRAPER, UT 84020-7976
(801) 449-1429
Mailing address
138 E 12300 S UNIT 860, DRAPER, UT 84020-7976
Taxonomy
Speciality
Code
Description
License number
State
247200000X
Other Technician
—
—
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
Primary
8480668-4405
UT
Other
Enumeration date
05/03/2016
Last updated
10/01/2022
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