Healthcare Provider Details

I. General information

NPI: 1083820302
Provider Name (Legal Business Name): JACK J. CLARK, D.C.P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 06/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6015 E STATE BLVD
FORT WAYNE IN
46815-7638
US

IV. Provider business mailing address

6015 E STATE BLVD
FORT WAYNE IN
46815-7638
US

V. Phone/Fax

Practice location:
  • Phone: 260-486-1886
  • Fax:
Mailing address:
  • Phone: 260-486-1886
  • Fax: 260-485-3958

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number08000717A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number08002245A
License Number StateIN

VIII. Authorized Official

Name: MRS. VALERIE BADIAC
Title or Position: OFFICE MANAGER
Credential:
Phone: 260-486-1886