Jack J. Clark, D.C.P.C.

Primary specialty

ChiropractorTaxonomy code 111N00000X

License

08000717A Issued in IN

Legal business name

JACK J. CLARK, D.C.P.C.

Practice address

6015 E State Blvd
Fort Wayne, IN 46815-7638

Phone

(260) 486-1886

NPI assigned

May 15, 2007

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mrs. Valerie Badiac

Title

Office Manager

Phone

(260) 486-1886

Specialties & licenses 2

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Enrolled in IN

Enrollment records 1

Locations

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Jack J Clark, D.C.

  • Chiropractor
  • Fort Wayne, IN
  • NPI 1902881014
  Medicare reassignment NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1179187200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1214524800000",
    "number": "1083820302",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "6015 E STATE BLVD",
            "city": "FORT WAYNE",
            "state": "IN",
            "postal_code": "468157638",
            "telephone_number": "260-486-1886",
            "fax_number": "260-485-3958"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "6015 E STATE BLVD",
            "city": "FORT WAYNE",
            "state": "IN",
            "postal_code": "468157638",
            "telephone_number": "260-486-1886"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "JACK J. CLARK, D.C.P.C.",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-05-15",
        "last_updated": "2008-06-27",
        "status": "A",
        "authorized_official_last_name": "BADIAC",
        "authorized_official_first_name": "VALERIE",
        "authorized_official_title_or_position": "OFFICE MANAGER",
        "authorized_official_telephone_number": "260-486-1886",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "111N00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Chiropractor",
            "state": "IN",
            "license": "08000717A",
            "primary": true
        },
        {
            "code": "111NR0400X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Chiropractor, Rehabilitation",
            "state": "IN",
            "license": "08002245A",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "100289660A",
            "state": "IN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Chiropractor in Fort Wayne, IN
• Providers in Fort Wayne, IN by specialty
• Chiropractor in Indiana

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 27, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.