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General NPI Number Information
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NPI Number | 1699983445
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Entity Type | Individual
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Provider Name | JON ALLEN CLARK PT
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Gender | Male
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Dates
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Enumeration Date | 05/17/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 2535 LONE STAR DR
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City | DALLAS
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State | TX
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Zip | 75212-6313
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Country | US
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Telephone | 214-467-9787
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Fax |
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Provider Business Mailing Address
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Address Line | 613 CATALPA RD
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City | FORT WORTH
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State | TX
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Zip | 76131-3537
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Country | US
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Telephone | 682-286-9449
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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 | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 1135218
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License Number State | TX
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