Individual
JACOB ALAN CLARK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MS, LAT, ATC
Contact information
Practice address
101 COLLEGE HTS, CISCO, TX 76437-1900
(254) 442-5198
Mailing address
1645 PR 2431, CLYDE, TX 79510-1900
(409) 489-2284
Taxonomy
Speciality
Code
Description
License number
State
2255A2300X
Athletic Trainer
Primary
AT8111
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
JEA013107880
BLUECROSS BLUESHIELD
TX
Enumeration date
06/25/2020
Last updated
06/25/2020
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