Provider Demographics
NPI:1336701911
Name:CLARK, JORDAN JOSEPH (PA-C)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:JOSEPH
Last Name:CLARK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BLDG 650 HUEBNER RD
Mailing Address - Street 2:
Mailing Address - City:FORY RILEY
Mailing Address - State:KS
Mailing Address - Zip Code:66442
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:814 MARSHALL DR
Practice Address - Street 2:
Practice Address - City:FORT RILEY
Practice Address - State:KS
Practice Address - Zip Code:66442
Practice Address - Country:US
Practice Address - Phone:785-240-1125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-03
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-02330363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS15-02330OtherKSBHA