Individual
MR. JACK MALCOLM CLARK III
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
LCSW
Contact information
Practice address
7711 MADONNA, SAN ANTONIO, TX 78216-6620
(210) 377-1133
(210) 377-1230
Mailing address
BROOKE ARMY MEDICAL CENTER, FT. SAM HOUSTON, TX 78234-4504
(210) 916-3704
(210) 916-8410
Taxonomy
Speciality
Code
Description
License number
State
1041C0700X
Clinical Social Worker
Primary
36151
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
175693402
—
TX
01
—
87614Q
CLARK BCBS
TX
Enumeration date
04/02/2007
Last updated
05/24/2021
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