Provider Demographics
NPI:1083820302
Name:JACK J. CLARK, D.C.P.C.
Entity type:Organization
Organization Name:JACK J. CLARK, D.C.P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:VALERIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BADIAC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-486-1886
Mailing Address - Street 1:6015 E STATE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46815-7638
Mailing Address - Country:US
Mailing Address - Phone:260-486-1886
Mailing Address - Fax:260-485-3958
Practice Address - Street 1:6015 E STATE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46815-7638
Practice Address - Country:US
Practice Address - Phone:260-486-1886
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08002245A111NR0400X
IN08000717A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100289660AMedicaid
IN197110Medicare PIN