Provider Demographics
NPI:1629695663
Name:CLARK, JACOB ALAN (MS, LAT, ATC)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:ALAN
Last Name:CLARK
Suffix:
Gender:M
Credentials:MS, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1645 PR 2431
Mailing Address - Street 2:
Mailing Address - City:CLYDE
Mailing Address - State:TX
Mailing Address - Zip Code:79510-1900
Mailing Address - Country:US
Mailing Address - Phone:409-489-2284
Mailing Address - Fax:
Practice Address - Street 1:101 COLLEGE HTS
Practice Address - Street 2:
Practice Address - City:CISCO
Practice Address - State:TX
Practice Address - Zip Code:76437-1900
Practice Address - Country:US
Practice Address - Phone:254-442-5198
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-25
Last Update Date:2020-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT81112255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXJEA013107880OtherBLUECROSS BLUESHIELD