Provider Demographics
NPI:1760247811
Name:CLARK, JAE H (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:JAE
Middle Name:H
Last Name:CLARK
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2230 GRAHAM ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19131-2203
Mailing Address - Country:US
Mailing Address - Phone:215-303-4818
Mailing Address - Fax:
Practice Address - Street 1:1651 BENJAMIN FRANKLIN PKWY
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19103-1284
Practice Address - Country:US
Practice Address - Phone:215-303-4818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-19
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART0057672255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer