Provider Demographics
NPI:1154386183
Name:CLARK, JEFFREY L (LAT, ATC, RET)
Entity type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:L
Last Name:CLARK
Suffix:
Gender:M
Credentials:LAT, ATC, RET
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9917 LAKEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE VILLAGE
Mailing Address - State:TX
Mailing Address - Zip Code:76227-5427
Mailing Address - Country:US
Mailing Address - Phone:469-417-8280
Mailing Address - Fax:940-440-0781
Practice Address - Street 1:2414 W UNIVERSITY DR
Practice Address - Street 2:SUITE 110
Practice Address - City:MCKINNEY
Practice Address - State:TX
Practice Address - Zip Code:75071-2810
Practice Address - Country:US
Practice Address - Phone:972-569-9050
Practice Address - Fax:972-569-9076
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT0438174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist