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General NPI Number Information
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NPI Number | 1083820302
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Entity Type | Organization
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Legal Business Name | JACK J. CLARK, D.C.P.C.
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Dates
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Enumeration Date | 05/15/2007
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Last Update Date | 06/27/2008
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Provider Practice Location Address
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Address Line | 6015 E STATE BLVD
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City | FORT WAYNE
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State | IN
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Zip | 46815-7638
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Country | US
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Telephone | 260-486-1886
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Fax |
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Provider Business Mailing Address
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Address Line | 6015 E STATE BLVD
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City | FORT WAYNE
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State | IN
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Zip | 46815-7638
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Country | US
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Telephone | 260-486-1886
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Fax | 260-485-3958
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MRS. VALERIE BADIAC
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Credential |
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Telephone | 260-486-1886
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111NR0400X
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Taxonomy Name | Rehabilitation Chiropractor
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License Number | 08002245A
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License Number State | IN
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Taxonomy #2
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 08000717A
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License Number State | IN
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