Provider Demographics
NPI:1467648048
Name:CLARK, JEFFREY (PTA)
Entity Type:Individual
Prefix:
First Name:JEFFREY
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 1:115 KELLI DR
Mailing Address - Street 2:
Mailing Address - City:FORNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75126-9564
Mailing Address - Country:US
Mailing Address - Phone:972-552-3419
Mailing Address - Fax:
Practice Address - Street 1:1010 W MAIN ST
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:TX
Practice Address - Zip Code:75652-2923
Practice Address - Country:US
Practice Address - Phone:903-657-6945
Practice Address - Fax:903-657-9061
Is Sole Proprietor?:No
Enumeration Date:2007-09-18
Last Update Date:2007-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2004982225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant