Provider Demographics
NPI:1902881014
Name:CLARK, JACK J (DC)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:J
Last Name:CLARK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6015 E STATE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46815-7638
Mailing Address - Country:US
Mailing Address - Phone:260-486-1886
Mailing Address - Fax:
Practice Address - Street 1:6015 E STATE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46815-7638
Practice Address - Country:US
Practice Address - Phone:260-486-1886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-12
Last Update Date:2010-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08000717A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100289660AMedicaid
IN000000086699OtherBLUE CROSS/BLUE SHIELD
IN000000086699OtherBLUE CROSS/BLUE SHIELD
IN100289660AMedicaid