Provider Demographics
NPI:1174126965
Name:CLARK, JUDSON
Entity type:Individual
Prefix:
First Name:JUDSON
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14245 W PARK AVE
Mailing Address - Street 2:
Mailing Address - City:BOULDER CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:95006-9304
Mailing Address - Country:US
Mailing Address - Phone:408-571-8439
Mailing Address - Fax:
Practice Address - Street 1:2500 HOSPITAL DR BLDG 3
Practice Address - Street 2:
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:CA
Practice Address - Zip Code:94040-4106
Practice Address - Country:US
Practice Address - Phone:650-863-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA769882163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult