Provider Demographics
NPI:1295735728
Name:CLARK, JAYNE ELIZABETH (MD)
Entity type:Individual
Prefix:DR
First Name:JAYNE
Middle Name:ELIZABETH
Last Name:CLARK
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:2180 E 4500 S
Mailing Address - Street 2:SUITE #185
Mailing Address - City:HOLLADAY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-4434
Mailing Address - Country:US
Mailing Address - Phone:801-272-6972
Mailing Address - Fax:801-272-6953
Practice Address - Street 1:2180 E 4500 S
Practice Address - Street 2:SUITE #185
Practice Address - City:HOLLADAY
Practice Address - State:UT
Practice Address - Zip Code:84117-4434
Practice Address - Country:US
Practice Address - Phone:801-272-6972
Practice Address - Fax:801-272-6953
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
UT165700-1205208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTDO 7419Medicare UPIN