Individual
DR. JACK J CLARK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
D.C.
Contact information
Practice address
6015 E STATE BLVD, FORT WAYNE, IN 46815-7638
(260) 486-1886
Mailing address
6015 E STATE BLVD, FORT WAYNE, IN 46815-7638
(260) 486-1886
Taxonomy
Speciality
Code
Description
License number
State
111N00000X
Chiropractor
Primary
08000717A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000086699
BLUE CROSS/BLUE SHIELD
IN
05
—
100289660A
—
IN
Enumeration date
12/12/2005
Last updated
06/22/2010
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