Provider Demographics
NPI:1831894906
Name:CLARK, JORDAN SHAYE (DC)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:SHAYE
Last Name:CLARK
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8108 CARNOUSTIE PL
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-3317
Mailing Address - Country:US
Mailing Address - Phone:732-850-8304
Mailing Address - Fax:
Practice Address - Street 1:8108 CARNOUSTIE PL
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-3317
Practice Address - Country:US
Practice Address - Phone:732-850-8304
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-30
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH14473111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor