Provider Demographics
NPI:1801230685
Name:CLACK, JONATHAN SHANE (MS, RD, LD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:SHANE
Last Name:CLACK
Suffix:
Gender:M
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 TERRY TRL
Mailing Address - Street 2:
Mailing Address - City:WEATHERFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76086-4601
Mailing Address - Country:US
Mailing Address - Phone:817-629-0420
Mailing Address - Fax:
Practice Address - Street 1:805 TERRY TRL
Practice Address - Street 2:
Practice Address - City:WEATHERFORD
Practice Address - State:TX
Practice Address - Zip Code:76086-4601
Practice Address - Country:US
Practice Address - Phone:817-629-0420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-23
Last Update Date:2018-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT82634133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered