MEDICARE: JULIE W. CLARK MS, RD, LD, CDE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	1002	IA

General Provider Information

NPI Number	:	1073748349
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JULIE W. CLARK MS, RD, LD, CDE

Provider Business Mailing Address
First Line	:	106 W WASHINGTON ST.
Second Line	:
City	:	JEFFERSON
State	:	IA
Zip	:	50129-1920
Country	:	US
Telephone Number	:	515-386-4153
Fax Number	:	515-386-0364

Provider Business Practice Location Address
First Line	:	106 W WASHINGTON ST.
Second Line	:
City	:	JEFFERSON
State	:	IA
Zip	:	50129-1920
Country	:	US
Telephone Number	:	515-386-4153
Fax Number	:	515-386-0364

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/15/2009
Last Update Date	:	05/08/2015

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