Individual
JONATHAN SHANE CLACK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MS, RD, LD
Contact information
Practice address
805 TERRY TRL, WEATHERFORD, TX 76086-4601
(817) 629-0420
Mailing address
805 TERRY TRL, WEATHERFORD, TX 76086-4601
(817) 629-0420
Taxonomy
Speciality
Code
Description
License number
State
133V00000X
Registered Dietitian
Primary
DT82634
TX
Other
Enumeration date
04/23/2013
Last updated
06/19/2018
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