=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477457737
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JADA CLARK
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/07/2026
-----------------------------------------------------
Last Update Date | 10/07/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 88 S LAKEVIEW DR
-----------------------------------------------------
City | GIBBSBORO
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08026-1229
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-484-5535
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 647 ROOSEVELT AVE
-----------------------------------------------------
City | GLASSBORO
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08028-3358
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 46TR01280800
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------