Active NPI
Robert Jon Clark Jr., MA, LPC
- Professional Counselor
- Dallas, TX
National Provider Identifier
1457614885
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Professional Counselor
- License
- 66476
- Practice address
- 4514 Cole Ave
Suite 600
Dallas, TX 75205-5412 - Phone
- (214) 907-0089
- NPI assigned
- Jun 20, 2012
- 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 |
|---|---|---|---|---|
| Professional Counselor | 101YP2500X | 66476 | TX | Primary |
Addresses
Primary practice location
4514 Cole Ave
Suite 600
Dallas, TX 75205-5412
Mailing address
4514 Cole Ave
Suite 600
Dallas, TX 75205-5412
Phone (214) 907-0089
Other identifiers 3
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 309292601 | Medicaid | TX | |
| 309292602 | Medicaid | TX | |
| 8380LC | Other | TX | BLUE CROSS BLUE SHIELD |
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 |
|---|---|---|---|
| 66476 | TX | MD | Professional Counselor |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1340150400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1466812800000",
"number": "1457614885",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "4514 COLE AVE",
"address_2": "SUITE 600",
"city": "DALLAS",
"state": "TX",
"postal_code": "752055412",
"telephone_number": "214-907-0089"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "4514 COLE AVE",
"address_2": "SUITE 600",
"city": "DALLAS",
"state": "TX",
"postal_code": "752055412",
"telephone_number": "214-907-0089"
}
],
"practiceLocations": [],
"basic": {
"last_name": "CLARK",
"first_name": "ROBERT",
"middle_name": "JON",
"name_suffix": "Jr.",
"credential": "MA, LPC",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2012-06-20",
"last_updated": "2016-06-25",
"status": "A"
},
"taxonomies": [
{
"code": "101YP2500X",
"taxonomy_group": "",
"desc": "Counselor, Professional",
"state": "TX",
"license": "66476",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "309292601",
"state": "TX"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "309292602",
"state": "TX"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BLUE CROSS BLUE SHIELD",
"identifier": "8380LC",
"state": "TX"
}
],
"endpoints": [],
"other_names": []
}Other providers in Dallas, TX
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 25, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.