Active NPI
Jacob C Clark
- Occupational Therapy Assistant
- Detroit, MI
National Provider Identifier
1205468006
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Occupational Therapy Assistant
- License
- 52002008500
- Practice address
- 7800 W Outer Dr Ste 300
Detroit, MI 48235-3458 - Phone
- (313) 340-4442
- NPI assigned
- Feb 10, 2020
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Occupational Therapy Assistant | 224Z00000X | 52002008500 | MI | Primary |
Addresses
Primary practice location
7800 W Outer Dr Ste 300
Detroit, MI 48235-3458
Mailing address
27085 Gratiot Ave Ste 101
Roseville, MI 48066-2984
Phone (586) 204-5560
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 52002008500 | MI | MD | Occupational Therapy Assistant |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Psygenics Inc | Occupational Therapy Assistant | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1581292800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1581292800000",
"number": "1205468006",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "27085 GRATIOT AVE STE 101",
"city": "ROSEVILLE",
"state": "MI",
"postal_code": "480662984",
"telephone_number": "586-204-5560"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "7800 W OUTER DR STE 300",
"city": "DETROIT",
"state": "MI",
"postal_code": "482353458",
"telephone_number": "313-340-4442"
}
],
"practiceLocations": [],
"basic": {
"last_name": "CLARK",
"first_name": "JACOB",
"middle_name": "C",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2020-02-10",
"last_updated": "2020-02-10",
"certification_date": "2020-02-10",
"status": "A"
},
"taxonomies": [
{
"code": "224Z00000X",
"taxonomy_group": "",
"desc": "Occupational Therapy Assistant",
"state": "MI",
"license": "52002008500",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Detroit, MI
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 10, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.