Provider Demographics
NPI:1760049068
Name:CLARK, JACOB DAVID (OD)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:DAVID
Last Name:CLARK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 ROSS CLARK CIR
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36301-2040
Mailing Address - Country:US
Mailing Address - Phone:334-793-2211
Mailing Address - Fax:
Practice Address - Street 1:2826 ROSS CLARK CIR STE 102
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-2017
Practice Address - Country:US
Practice Address - Phone:334-793-2633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-22
Last Update Date:2025-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS-E20-TA-B53152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist