MEDICARE: DR. JAYNE ELIZABETH CLARK M.D.

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	208100000X	Physical Medicine & Rehabilitation Physician	165700-1205	UT

General Provider Information

NPI Number	:	1295735728
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JAYNE ELIZABETH CLARK M.D.

Provider Business Mailing Address
First Line	:	2180 E 4500 S
Second Line	:	SUITE #185
City	:	HOLLADAY
State	:	UT
Zip	:	84117-4434
Country	:	US
Telephone Number	:	801-272-6972
Fax Number	:	801-272-6953

Provider Business Practice Location Address
First Line	:	2180 E 4500 S
Second Line	:	SUITE #185
City	:	HOLLADAY
State	:	UT
Zip	:	84117-4434
Country	:	US
Telephone Number	:	801-272-6972
Fax Number	:	801-272-6953

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

Provider Enumeration Date	:	07/27/2005
Last Update Date	:	07/08/2007

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