Provider Demographics
NPI:1134448525
Name:CLARK, JASON D (DO)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:D
Last Name:CLARK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:239 COLONNADE BLVD STE 2
Mailing Address - Street 2:
Mailing Address - City:STATE COLLEGE
Mailing Address - State:PA
Mailing Address - Zip Code:16803-2668
Mailing Address - Country:US
Mailing Address - Phone:582-220-2310
Mailing Address - Fax:582-220-2311
Practice Address - Street 1:239 COLONNADE BLVD STE 2
Practice Address - Street 2:
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16803-2668
Practice Address - Country:US
Practice Address - Phone:582-220-2310
Practice Address - Fax:582-220-2311
Is Sole Proprietor?:No
Enumeration Date:2010-05-25
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2015-00059207X00000X
GA071601207X00000X
OH58.003143207X00000X
PAOS018039207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1031367111Medicaid
PA517503Medicare PIN