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General NPI Number Information
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NPI Number | 1992512206
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Entity Type | Individual
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Provider Name | JACE CLINKENBEARD PT, DPT
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Gender | Male
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Dates
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Enumeration Date | 12/11/2024
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Last Update Date | 12/16/2024
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Provider Practice Location Address
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Address Line | 1201 HERITAGE CIR
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City | PAWNEE
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State | OK
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Zip | 74058-3744
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Country | US
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Telephone | 918-762-2517
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Fax |
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Provider Business Mailing Address
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Address Line | 116 LEANING TREE RD
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City | FORT GIBSON
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State | OK
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Zip | 74434-7611
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Country | US
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Telephone | 918-685-0935
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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 | 6644
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License Number State | OK
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