NPI |
1750678108 |
Code indicating whether the provider is operating as a sole proprietor. Codes are: Y = Yes; N = No |
Entity Type Code |
2 |
Code indicating whether the provider is operating as a sole proprietor. Codes are: Y = Yes; N = No |
Employer Identification Number EIN |
|
The Employer Identification Number (EIN), assigned by the IRS, of the provider being identified. |
Provider Organization Name Legal Business Name |
JERRY W CLARK, PHD, LTD. |
The name of the organization provider. If the provider is an organization, this is the legal business name. |
Provider Other Organization Name |
BEHAVIORAL SERVICES LTD |
The first name of the provider, if the provider
is an individual. |
Provider Other Organization Name Type Code |
4 |
Code identifying the type of other name. Codes are: 1 = former name; 2 = professional
name; 3 = doing business as (d/b/ a) name; 4 = former legal business name; 5 = other. |
Provider First Line Business Practice Location Address |
200 SO. VIRGINIA ST. |
The first line location address of the provider
being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box. |
Provider Second Line Business Practice Location Address |
8TH FLOOR |
The name prefix or salutation of the provider
if the provider is an individual; for example, Mr., Mrs., or Corporal. |
Provider Business Practice Location Address City Name |
RENO |
The city name in the location address of the provider being identified. |
Provider Business Practice Location Address State Name |
NV |
The city name in the location address of the provider being identified. |
Provider Business Practice Location Address Postal Code |
895012405 |
The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. |
Provider Business Practice Location Address Country Code If outside U S |
US |
The country code in the location address of the provider being identified. |
Provider Business Practice Location Address Telephone Number |
7757720392 |
The telephone number associated with the location address of the provider being identified. |
Provider Business Practice Location Address Fax Number |
7757720392 |
The fax number associated with the location
address of the provider being identified. |
Provider Enumeration Date |
7/6/2011 |
The date the provider was assigned a unique identifier (assigned an NPI). |
Last Update Date |
7/13/2011 |
The State code in the location of the provider
being identified. |
Authorized Official Last Name |
CLARK |
The last name of the person authorized to submit the NPI application or to change NPS data for a health care provider. |
Authorized Official First Name |
JERRY |
The country code in the location address of the provider being identified. |
Authorized Official Middle Name |
W |
The middle name of the authorized official. |
Authorized Official Title or Position |
OWNER |
The title or position of the authorized official. |
Authorized Official Telephone Number |
7757720392 |
The 10-position telephone number of the authorized official. |
Healthcare Provider Taxonomy Code 1 |
1041C0700X |
The code designating the provider’s gender if the provider is a person. |
Provider License Number 1 |
00004-C |
Code designating the provider type, classification,
and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1. |
Provider License Number State Code 1 |
NV |
The license number issued to the provider being identified. The NPS can accommodate
multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with ‘‘provider taxonomy code’’. |
Healthcare Provider Primary Taxonomy Switch 1 |
Y |
|
Other Provider Identifier 1 |
1245454628 |
|
Other Provider Identifier Type Code 1 |
05 |
|
Other Provider Identifier State 1 |
NV |
The code representing the State that issued the license to the provider being identified. This field can accommodate multiple States. It is associated with ‘‘provider license number. |
Is Organization Subpart |
N |
|
Authorized Official Name Prefix Text |
DR. |
|
Authorized Official Credential Text |
PH.D. |
|
Healthcare Provider Taxonomy Group 1 |
193400000X SINGLE SPECIALTY GROUP |
|