Provider Demographics
NPI:1932508165
Name:CLARK, JONATHAN DANIEL (MS, LAT, ATC)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:DANIEL
Last Name:CLARK
Suffix:
Gender:M
Credentials:MS, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:925 FRANKLIN ST SE STE A
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35801-4307
Mailing Address - Country:US
Mailing Address - Phone:256-265-5000
Mailing Address - Fax:
Practice Address - Street 1:11306 COUNTY LINE RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35756-2011
Practice Address - Country:US
Practice Address - Phone:256-216-5313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-13
Last Update Date:2014-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL13782255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
2000006545OtherBOC CERTIFIED ATHLETIC TRAINER
AL1378OtherSTATE OF ALABAMA BOARD OF ATHLETIC TRAINERS