Provider Demographics
NPI:1639285174
Name:JEFFERY A CLARK, DC, PC
Entity Type:Organization
Organization Name:JEFFERY A CLARK, DC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFERY
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:248-391-4600
Mailing Address - Street 1:2991 S BALDWIN RD
Mailing Address - Street 2:
Mailing Address - City:LAKE ORION
Mailing Address - State:MI
Mailing Address - Zip Code:48360-1665
Mailing Address - Country:US
Mailing Address - Phone:248-391-4600
Mailing Address - Fax:248-391-1910
Practice Address - Street 1:2991 S BALDWIN RD
Practice Address - Street 2:
Practice Address - City:LAKE ORION
Practice Address - State:MI
Practice Address - Zip Code:48360-1665
Practice Address - Country:US
Practice Address - Phone:248-391-4600
Practice Address - Fax:248-391-1910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301006916111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI143126777Medicaid
MIBLUE CROSSOtherBLUE CROSS MICHIGAN
U66492Medicare UPIN
MI0P34300Medicare PIN