Basic Information
| Provider Information | |||||||||
| NPI: | 1881825768 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLAYCOMB | ||||||||
| FirstName: | JUSTIN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 PLEASANT ST | ||||||||
| Address2: | |||||||||
| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503091406 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1200 PLEASANT ST | ||||||||
| Address2: | |||||||||
| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503091406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152415926 | ||||||||
| FaxNumber: | 5152415127 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2009 | ||||||||
| LastUpdateDate: | 10/17/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041S0200X | 007301 | IA | Y | Behavioral Health & Social Service Providers | Social Worker | School |
No ID Information.