Provider Demographics
NPI:1679018303
Name:CLARK, BRETT JACOB (DC)
Entity Type:Individual
Prefix:DR
First Name:BRETT
Middle Name:JACOB
Last Name:CLARK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2718 FORUM BLVD STE 2
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-5451
Mailing Address - Country:US
Mailing Address - Phone:314-704-1095
Mailing Address - Fax:314-873-1887
Practice Address - Street 1:2718 FORUM BLVD STE 2
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-5451
Practice Address - Country:US
Practice Address - Phone:314-704-1095
Practice Address - Fax:314-873-1887
Is Sole Proprietor?:No
Enumeration Date:2017-01-04
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016044966111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor