Provider Demographics
NPI:1396190559
Name:CLARK, DACY JAEL (PT, DPT)
Entity type:Individual
Prefix:MRS
First Name:DACY
Middle Name:JAEL
Last Name:CLARK
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:MRS
Other - First Name:JAEL
Other - Middle Name:
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:6100 SEAGULL ST NE STE 102
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-2500
Mailing Address - Country:US
Mailing Address - Phone:505-823-2411
Mailing Address - Fax:505-858-0650
Practice Address - Street 1:6100 SEAGULL ST NE STE 102
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-2500
Practice Address - Country:US
Practice Address - Phone:505-823-2411
Practice Address - Fax:505-858-0650
Is Sole Proprietor?:No
Enumeration Date:2016-04-25
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4693225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist