Provider Demographics
NPI:1649289778
Name:CLEMENT, JAC A (PA-C)
Entity type:Individual
Prefix:MR
First Name:JAC
Middle Name:A
Last Name:CLEMENT
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1866
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-1866
Mailing Address - Country:US
Mailing Address - Phone:920-445-7210
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:820 ARBUTUS AVE
Practice Address - Street 2:
Practice Address - City:OCONTO
Practice Address - State:WI
Practice Address - Zip Code:54153-2004
Practice Address - Country:US
Practice Address - Phone:920-835-1100
Practice Address - Fax:920-835-1099
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI603-023363A00000X
IL085-001577363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42940500Medicaid
WI42940500Medicaid