MEDICARE: JESSIE S CLARKE DPT

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	225100000X	Physical Therapist	1224243	TX

General Provider Information

NPI Number	:	1811537921
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSIE S CLARKE DPT

Provider Business Mailing Address
First Line	:	305 W MILL ST
Second Line	:
City	:	LIVINGSTON
State	:	TX
Zip	:	77351-3299
Country	:	US
Telephone Number	:	936-327-4084
Fax Number	:	936-327-1201

Provider Business Practice Location Address
First Line	:	305 W MILL ST
Second Line	:
City	:	LIVINGSTON
State	:	TX
Zip	:	77351-3299
Country	:	US
Telephone Number	:	936-327-4084
Fax Number	:	936-327-1201

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

Provider Enumeration Date	:	01/07/2020
Last Update Date	:	01/07/2020

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