Provider Demographics
NPI:1063757003
Name:CLARK, JESSICA LYNN (PT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:CLARK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1705 CHRISTY DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65101-5195
Mailing Address - Country:US
Mailing Address - Phone:573-659-5515
Mailing Address - Fax:573-659-5516
Practice Address - Street 1:1705 CHRISTY DR
Practice Address - Street 2:SUITE 200
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65101-5195
Practice Address - Country:US
Practice Address - Phone:573-659-5515
Practice Address - Fax:573-659-5516
Is Sole Proprietor?:No
Enumeration Date:2012-12-03
Last Update Date:2012-12-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2012027636225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist