Healthcare Provider Details

I. General information

NPI: 1790785905
Provider Name (Legal Business Name): JAY CLARK HANS AU.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2005
Last Update Date: 06/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 COACHMAN PIKE
LEDYARD CT
06339-1305
US

IV. Provider business mailing address

7 COACHMAN PIKE
LEDYARD CT
06339-1305
US

V. Phone/Fax

Practice location:
  • Phone: 860-464-9779
  • Fax:
Mailing address:
  • Phone: 860-464-9779
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number122
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: