Provider Demographics
NPI:1710018395
Name:CLARK, JEREMY R (DC)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:R
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 1:100 N KENNEDY BLVD
Mailing Address - Street 2:
Mailing Address - City:VANDALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62471-2314
Mailing Address - Country:US
Mailing Address - Phone:618-531-1141
Mailing Address - Fax:
Practice Address - Street 1:100 N KENNEDY BLVD
Practice Address - Street 2:
Practice Address - City:VANDALIA
Practice Address - State:IL
Practice Address - Zip Code:62471-2314
Practice Address - Country:US
Practice Address - Phone:618-531-1141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2011-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILIL038-009768111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK19248Medicare PIN