MEDICARE: JONATHAN CLARK

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	2255A2300X	Athletic Trainer	AT001654	GA
2	2255A2300X	Athletic Trainer	AT0000001292	TN

General Provider Information

NPI Number	:	1841696820
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JONATHAN CLARK

Provider Business Mailing Address
First Line	:	922 FEDERAL ST
Second Line	:
City	:	CHATTANOOGA
State	:	TN
Zip	:	37405-2931
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	14049 SCENIC HWY
Second Line	:
City	:	LOOKOUT MOUNTAIN
State	:	GA
Zip	:	30750-4100
Country	:	US
Telephone Number	:	706-419-1523
Fax Number	:

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

Provider Enumeration Date	:	11/18/2014
Last Update Date	:	11/18/2014

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Directions to “ JONATHAN CLARK ” Practice Location

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