Provider Demographics
NPI:1215389929
Name:CLARK, JESSICA NICOLE (DPT)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:NICOLE
Last Name:CLARK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:N
Other - Last Name:FRANK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:15832 E OTERO CIR
Mailing Address - Street 2:
Mailing Address - City:CENTENNIAL
Mailing Address - State:CO
Mailing Address - Zip Code:80112-4778
Mailing Address - Country:US
Mailing Address - Phone:202-412-1754
Mailing Address - Fax:
Practice Address - Street 1:13199 E MONTVIEW BLVD STE 100
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80045-7202
Practice Address - Country:US
Practice Address - Phone:303-724-1510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-06
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12978482251P0200X
CO0018095225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics