Individual
JACOB TYLER CLARK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
2845 GREENBRIER RD, GREEN BAY, WI 54311-6519
(920) 288-4060
(920) 288-4067
Mailing address
1035 KEPLER DR, GREEN BAY, WI 54311-8320
(920) 490-9046
(920) 405-8005
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
Primary
6446-851
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100057535
—
WI
Enumeration date
04/04/2016
Last updated
04/21/2026
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