=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831894906
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JORDAN SHAYE CLARK DC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/30/2023
-----------------------------------------------------
Last Update Date | 03/30/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8108 CARNOUSTIE PL
-----------------------------------------------------
City | PORT ST LUCIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34986-3317
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-850-8304
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8108 CARNOUSTIE PL
-----------------------------------------------------
City | PORT ST LUCIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34986-3317
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-850-8304
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CH14473
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------