MEDICARE: JORDAN SHAYE CLARK DC

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	111N00000X	Chiropractor	CH14473	FL

General Provider Information

NPI Number	:	1831894906
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JORDAN SHAYE CLARK DC

Provider Business Mailing Address
First Line	:	8108 CARNOUSTIE PL
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34986-3317
Country	:	US
Telephone Number	:	732-850-8304
Fax Number	:

Provider Business Practice Location Address
First Line	:	8108 CARNOUSTIE PL
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34986-3317
Country	:	US
Telephone Number	:	732-850-8304
Fax Number	:

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

Provider Enumeration Date	:	03/30/2023
Last Update Date	:	03/30/2023

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