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General NPI Number Information
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NPI Number | 1679943328
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Entity Type | Individual
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Provider Name | JONATHAN WILSON CLARK OTR/L
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Gender | Male
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Dates
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Enumeration Date | 10/06/2015
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Last Update Date | 10/06/2015
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Provider Practice Location Address
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Address Line | 3175 POCAHONTAS RD
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City | BAKER CITY
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State | OR
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Zip | 97814-1434
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Country | US
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Telephone | 541-523-4415
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Fax |
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Provider Business Mailing Address
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Address Line | 3510 8TH DR
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City | BAKER CITY
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State | OR
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Zip | 97814-1516
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Country | US
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Telephone | 801-413-4395
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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 | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | 342831
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License Number State | OR
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