Active NPI
Jeffrey Paul Clark, M.A.
- Clinical Psychologist
- Rochester, MN
National Provider Identifier
1003979600
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Psychologist
- License
- LP3310
- Practice address
- 1932 Viking Dr NW
Rochester, MN 55901-2460 - Phone
- (180) 042-2016
- NPI assigned
- Dec 18, 2006
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Psychologist | 103TC0700X | LP3310 | MN | Primary |
Addresses
Primary practice location
1932 Viking Dr NW
Rochester, MN 55901-2460
Mailing address
1926 26TH Ave NW
Rochester, MN 55901-8064
Phone (507) 261-2777
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- Credentials
- Master of Arts
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| LP3310 | MN | MD | Clinical Psychologist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1166400000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1003979600",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1926 26TH AVE NW",
"city": "ROCHESTER",
"state": "MN",
"postal_code": "559018064",
"telephone_number": "507-261-2777"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1932 VIKING DR NW",
"city": "ROCHESTER",
"state": "MN",
"postal_code": "559012460",
"telephone_number": "180-042-2016"
}
],
"practiceLocations": [],
"basic": {
"last_name": "CLARK",
"first_name": "JEFFREY",
"middle_name": "PAUL",
"credential": "M.A.",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2006-12-18",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "103TC0700X",
"taxonomy_group": "",
"desc": "Psychologist, Clinical",
"state": "MN",
"license": "LP3310",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Rochester, MN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.