Clark, Jack J
Clark, Jack J is an sole proprietor health care provider with primary practice located at 6015 E State Blvd , Fort Wayne IN 46815-7638. He recently has only one registered license in Chiropractic Providers / Chiropractor, which is considered as his primary health care specialty. Clark, Jack J can be contacted via phone (260) 486-1886.Contact Information
Primary practice address
6015 E State Blvd
Fort Wayne IN 46815-7638
Phone: (260) 486-1886
Fax:
Website:
Health care specialties
| Specialty | Code | License # | State |
|---|---|---|---|
| Chiropractic Providers / Chiropractor | 111N00000X | 08000717A | Indiana |
Profile Details
| NPI number | 1902881014 |
|---|---|
| LBN Legal business name | Clark, Jack J |
| Credentials | Doctor of Chiropractic (DC) |
| Entity | Individual |
| Sole proprietor 1 | Yes |
| Enumeration date | Dec 12th, 2005 |
| Last updated | Jun 22nd, 2010 - about 16 years ago |
1 A sole proprietor/sole proprietorship is an individual, and in that capacity, is qualified for a solitary NPI number. The sole proprietor have to apply for the NPI number using his or her own particular Social Security Number (SSN), instead of Employer Identification Number (EIN) regardless of whether he/she has an EIN.
Identifiers
| State | Type | Number | Issuer |
|---|---|---|---|
| All States | NPI | 1902881014 | NPPES |
| Indiana | MEDICAID | 100289660A | |
| Indiana | Other | 000000086699 |
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