Provider Demographics
NPI:1992867709
Name:CLARK, JEFFERY (DC)
Entity Type:Individual
Prefix:
First Name:JEFFERY
Middle Name:
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 1:3202 NORTHWEST HWY
Mailing Address - Street 2:STE E
Mailing Address - City:CARY
Mailing Address - State:IL
Mailing Address - Zip Code:60013-3507
Mailing Address - Country:US
Mailing Address - Phone:847-516-8000
Mailing Address - Fax:847-516-8959
Practice Address - Street 1:3202 NORTHWEST HWY
Practice Address - Street 2:STE E
Practice Address - City:CARY
Practice Address - State:IL
Practice Address - Zip Code:60013-3507
Practice Address - Country:US
Practice Address - Phone:847-516-8000
Practice Address - Fax:847-516-8959
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-008727111N00000X
IL3585111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL05622903OtherBLUE CROSS BLUE SHIELD
ILU75680Medicare UPIN
ILK40038Medicare PIN