Provider Demographics
NPI:1174850739
Name:CLARK, JILL A (MA, LMT, NCTMB)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:A
Last Name:CLARK
Suffix:
Gender:F
Credentials:MA, LMT, NCTMB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 C UTICA ST.
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:NY
Mailing Address - Zip Code:13346
Mailing Address - Country:US
Mailing Address - Phone:607-244-2790
Mailing Address - Fax:
Practice Address - Street 1:54 C UTICA ST.
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:NY
Practice Address - Zip Code:13346
Practice Address - Country:US
Practice Address - Phone:607-244-2790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-03
Last Update Date:2009-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022029225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist