Provider Demographics
NPI:1003864620
Name:CLARK, JACOB SCOTT (DC)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:SCOTT
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 1:854C KALISTE SALOOM RD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-4210
Mailing Address - Country:US
Mailing Address - Phone:337-232-3353
Mailing Address - Fax:337-232-9304
Practice Address - Street 1:854C KALISTE SALOOM RD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-4210
Practice Address - Country:US
Practice Address - Phone:337-232-3353
Practice Address - Fax:337-232-9304
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1322111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAU97711Medicare UPIN
LA4C889CT32Medicare PIN