Provider Demographics
NPI:1083682736
Name:CLACK, JAYMIE CLAIRE (OTRL)
Entity Type:Individual
Prefix:MRS
First Name:JAYMIE
Middle Name:CLAIRE
Last Name:CLACK
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12619 LAUREL MEADOW WAY
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77014
Mailing Address - Country:US
Mailing Address - Phone:281-893-4076
Mailing Address - Fax:281-469-5559
Practice Address - Street 1:11811 FM 1960 WEST
Practice Address - Street 2:SUITE 102
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77065
Practice Address - Country:US
Practice Address - Phone:281-469-8163
Practice Address - Fax:281-469-5559
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX110009225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8T1955OtherBLUE CROSS BLUE SHIELD