Provider Demographics
NPI:1093206773
Name:CLARK, JACOB EARL (MS, AT, NR-EMT)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:EARL
Last Name:CLARK
Suffix:
Gender:M
Credentials:MS, AT, NR-EMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3503 WILLOW BROOK LN
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43611-3018
Mailing Address - Country:US
Mailing Address - Phone:419-906-5086
Mailing Address - Fax:
Practice Address - Street 1:116 S LANE ST
Practice Address - Street 2:
Practice Address - City:BLISSFIELD
Practice Address - State:MI
Practice Address - Zip Code:49228-1206
Practice Address - Country:US
Practice Address - Phone:517-486-5278
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-29
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer