Provider Demographics
NPI:1366417487
Name:CLARK, JEFFREY PAUL (DC)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:PAUL
Last Name:CLARK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9633 MARKET PLACE
Mailing Address - Street 2:SUITE #103
Mailing Address - City:LAKE STEVENS
Mailing Address - State:WA
Mailing Address - Zip Code:98258
Mailing Address - Country:US
Mailing Address - Phone:425-335-0300
Mailing Address - Fax:425-335-0302
Practice Address - Street 1:9633 MARKET PLACE
Practice Address - Street 2:SUITE #103
Practice Address - City:LAKE STEVENS
Practice Address - State:WA
Practice Address - Zip Code:98258
Practice Address - Country:US
Practice Address - Phone:425-335-0300
Practice Address - Fax:425-335-0302
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00002638111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA350052980OtherRAILROAD MEDICARE
WA43630OtherWORKERS COMP
WAU-69682Medicare UPIN
WAG8864764Medicare PIN
WA43630OtherWORKERS COMP
WAAB08870Medicare ID - Type Unspecified