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General NPI Number Information
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NPI Number | 1013614304
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Entity Type | Individual
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Provider Name | JACOB CLARK
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Gender | Male
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Dates
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Enumeration Date | 02/08/2023
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Last Update Date | 04/07/2023
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Provider Practice Location Address
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Address Line | 530 NE GLEN OAK AVE
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City | PEORIA
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State | IL
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Zip | 61637-0001
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Country | US
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Telephone | 309-655-2000
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Fax |
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Provider Business Mailing Address
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Address Line | 4537 TUNDRA LN
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City | MCFARLAND
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State | WI
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Zip | 53558-9158
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Country | US
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Telephone | 605-521-8056
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number |
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License Number State |
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