Provider Demographics
NPI:1538253174
Name:CLARK, JOY JEAN (PHD)
Entity type:Individual
Prefix:
First Name:JOY
Middle Name:JEAN
Last Name:CLARK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:JOY
Other - Middle Name:JEAN
Other - Last Name:SMITH CLARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:120 E. KIMBALL AVENUE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92543
Mailing Address - Country:US
Mailing Address - Phone:951-392-3219
Mailing Address - Fax:951-392-3087
Practice Address - Street 1:120 E. KIMBALL AVENUE
Practice Address - Street 2:SUITE 2
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92543
Practice Address - Country:US
Practice Address - Phone:951-392-3219
Practice Address - Fax:951-392-3087
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY11556103TC0700X, 103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
Provider Identifiers
StateIdentifier IDID TypeIssuer
0PL115560OtherMEDICARE ID
CAPSY11556OtherSTATE LICENSE NUMBER
CAPSY115560Medicaid