Provider Demographics
NPI:1730437815
Name:CLARK, JOANNA GWEN (PT)
Entity type:Individual
Prefix:
First Name:JOANNA
Middle Name:GWEN
Last Name:CLARK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2744 RHEEM AVE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:CA
Mailing Address - Zip Code:94804-1077
Mailing Address - Country:US
Mailing Address - Phone:510-621-9364
Mailing Address - Fax:
Practice Address - Street 1:2744 RHEEM AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:CA
Practice Address - Zip Code:94804-1077
Practice Address - Country:US
Practice Address - Phone:510-621-9364
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-21
Last Update Date:2025-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
374J00000X
CAPT 38876225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No374J00000XNursing Service Related ProvidersDoula