Provider Demographics
NPI:1457632705
Name:CLARK, JASON (PTA)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 ELM STREET
Mailing Address - Street 2:
Mailing Address - City:ROCKLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49960-0261
Mailing Address - Country:US
Mailing Address - Phone:906-886-2660
Mailing Address - Fax:
Practice Address - Street 1:1001 GIESAU DR
Practice Address - Street 2:
Practice Address - City:ONTONAGON
Practice Address - State:MI
Practice Address - Zip Code:49953-1454
Practice Address - Country:US
Practice Address - Phone:906-884-6092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-31
Last Update Date:2011-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL2065720225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant