Provider Demographics
NPI:1538532361
Name:CLARK, JOHNATHAN (DC)
Entity type:Individual
Prefix:DR
First Name:JOHNATHAN
Middle Name:
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 1:542 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:MI
Mailing Address - Zip Code:49345-1547
Mailing Address - Country:US
Mailing Address - Phone:616-887-2178
Mailing Address - Fax:
Practice Address - Street 1:542 S STATE ST
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:MI
Practice Address - Zip Code:49345-1547
Practice Address - Country:US
Practice Address - Phone:616-887-2178
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-02
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301010324111N00000X
PADC011132111N00000X
VA0104557282111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA504995ZU84OtherMEDICARE