Provider Demographics
NPI:1023359155
Name:CLARK, JAYMOND RYAN (DC)
Entity Type:Individual
Prefix:MR
First Name:JAYMOND
Middle Name:RYAN
Last Name:CLARK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:JAY
Other - Middle Name:
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:2100 MEADOWLAKE RD STE 10
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72032-2569
Mailing Address - Country:US
Mailing Address - Phone:501-513-3322
Mailing Address - Fax:501-513-3065
Practice Address - Street 1:2100 MEADOWLAKE RD STE 10
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72032-2569
Practice Address - Country:US
Practice Address - Phone:501-513-3322
Practice Address - Fax:501-513-3065
Is Sole Proprietor?:No
Enumeration Date:2013-03-14
Last Update Date:2018-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12457111N00000X
KY5441111N00000X
AR16169111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor