Provider Demographics
NPI:1568711513
Name:CLARK, JASON E
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:E
Last Name:CLARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4615 PHILIPS HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-7265
Mailing Address - Country:US
Mailing Address - Phone:904-739-7006
Mailing Address - Fax:904-737-3412
Practice Address - Street 1:4615 PHILIPS HIGHWAY
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-7265
Practice Address - Country:US
Practice Address - Phone:904-739-7006
Practice Address - Fax:904-737-3412
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-06
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL005491100251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL005491100Medicaid