Provider Demographics
NPI:1346492477
Name:CLARKE, MARY JANE (DPT)
Entity Type:Individual
Prefix:DR
First Name:MARY JANE
Middle Name:
Last Name:CLARKE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 MCDONALD AVE APT 1D
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11218-1433
Mailing Address - Country:US
Mailing Address - Phone:718-438-9648
Mailing Address - Fax:
Practice Address - Street 1:221 MCDONALD AVE APT 1D
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11218-1433
Practice Address - Country:US
Practice Address - Phone:718-438-9648
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-21
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025092-1172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker