Provider Demographics
NPI:1063805844
Name:CLARK, JEFFREY (AT/ATC/CES)
Entity type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:AT/ATC/CES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 REBER AVE
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:OH
Mailing Address - Zip Code:43130-1761
Mailing Address - Country:US
Mailing Address - Phone:740-503-8092
Mailing Address - Fax:
Practice Address - Street 1:315 REBER AVE
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:OH
Practice Address - Zip Code:43130-1761
Practice Address - Country:US
Practice Address - Phone:740-503-8092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-18
Last Update Date:2015-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAT 15822255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer