Provider Demographics
NPI:1275581902
Name:CLARK, BETTY JO (DC)
Entity Type:Individual
Prefix:DR
First Name:BETTY
Middle Name:JO
Last Name:CLARK
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8000 DALLAS ST
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-4277
Mailing Address - Country:US
Mailing Address - Phone:479-484-0805
Mailing Address - Fax:479-452-1475
Practice Address - Street 1:8000 DALLAS ST
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-4277
Practice Address - Country:US
Practice Address - Phone:479-484-0805
Practice Address - Fax:479-452-1475
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1597111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
U91038Medicare UPIN
5X058Medicare ID - Type Unspecified