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NPI Code Detail

MEDICARE: JASON CLARK OTR/L

MEDICARE: JASON CLARK OTR/L
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
1225X00000XOccupational Therapist4141TN

General Provider Information

NPI Number : 1508150301
Entity Type Code : Individual
Provider Name (Legal Business Name) : JASON CLARK OTR/L
Provider Business Mailing Address
First Line : 420 WYNDHAM DR
Second Line :
City : GRAY
State : TN
Zip : 37615-5229
Country : US
Telephone Number : 352-359-6252
Fax Number :
Provider Business Practice Location Address
First Line : 140 TECHNOLOGY LN
Second Line :
City : JOHNSON CITY
State : TN
Zip : 37604-2004
Country : US
Telephone Number : 423-979-0798
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/09/2011
Last Update Date : 06/09/2011

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Directions to “ JASON CLARK OTR/L” Practice Location

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