Provider Demographics
NPI:1235255837
Name:CLARK, JAY BRADFORD (DSCPT, MPT)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:BRADFORD
Last Name:CLARK
Suffix:
Gender:M
Credentials:DSCPT, MPT
Other - Prefix:DR
Other - First Name:BRADFORD
Other - Middle Name:J
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DSCPT, MPT
Mailing Address - Street 1:4807 BENSON AVE.
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21227-1530
Mailing Address - Country:US
Mailing Address - Phone:410-242-8963
Mailing Address - Fax:410-242-8965
Practice Address - Street 1:4807 BENSON AVE.
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21227-1530
Practice Address - Country:US
Practice Address - Phone:410-242-8963
Practice Address - Fax:410-242-8965
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2009-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD18491174400000X, 2251X0800X, 2251G0304X, 2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No174400000XOther Service ProvidersSpecialist
No2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD020880900Medicaid
MD103539600Medicare UPIN
170SMedicare UPIN
MD170SMedicare UPIN