Active NPI
Jacob Alan Clark, MS, LAT, ATC
- Athletic Trainer
- Cisco, TX
National Provider Identifier
1629695663
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Athletic Trainer
- License
- AT8111
- Practice address
- 101 College HTS
Cisco, TX 76437-1900 - Phone
- (254) 442-5198
- NPI assigned
- Jun 25, 2020
- Last updated
- Jun 25, 2020
- Sex
- Male
- Sole proprietor
- Yes
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 |
|---|---|---|---|---|
| Athletic Trainer | 2255A2300X | AT8111 | TX | Primary |
Addresses
Primary practice location
101 College HTS
Cisco, TX 76437-1900
Mailing address
1645 PR 2431
Clyde, TX 79510-1900
Phone (409) 489-2284
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| JEA013107880 | Other | TX | BLUECROSS BLUESHIELD |
Electronic endpoints 1
| Type | Endpoint | Use | Affiliation |
|---|---|---|---|
| CONNECT URL | jacob.clark@cisco.edu | Direct |
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
- Credentials
- Master of Science
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| AT8111 | TX | MD | Athletic Trainer |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1593043200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1593043200000",
"number": "1629695663",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1645 PR 2431",
"city": "CLYDE",
"state": "TX",
"postal_code": "795101900",
"telephone_number": "409-489-2284"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "101 COLLEGE HTS",
"city": "CISCO",
"state": "TX",
"postal_code": "764371900",
"telephone_number": "254-442-5198"
}
],
"practiceLocations": [],
"basic": {
"last_name": "CLARK",
"first_name": "JACOB",
"middle_name": "ALAN",
"credential": "MS, LAT, ATC",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2020-06-25",
"last_updated": "2020-06-25",
"certification_date": "2020-06-25",
"status": "A"
},
"taxonomies": [
{
"code": "2255A2300X",
"taxonomy_group": "",
"desc": "Specialist/Technologist, Athletic Trainer",
"state": "TX",
"license": "AT8111",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BLUECROSS BLUESHIELD",
"identifier": "JEA013107880",
"state": "TX"
}
],
"endpoints": [
{
"endpointType": "CONNECT",
"endpointTypeDescription": "CONNECT URL",
"endpoint": "jacob.clark@cisco.edu",
"affiliation": "N",
"endpointDescription": "email",
"use": "DIRECT",
"useDescription": "Direct",
"contentType": "CSV",
"contentTypeDescription": "CSV",
"address_1": "101 College Hts",
"city": "Cisco",
"state": "TX",
"country_code": "US",
"postal_code": "764371900",
"country_name": "United States",
"address_type": "DOM"
}
],
"other_names": []
}Other providers in Cisco, TX
- Ana Rosa Carrillo, FNP-BC
- Cisco Chiropractic LLC
- Cisco Independent School District
- Cisco Long Term Care, LLC (Homestead Nursing and Rehabilitation of Cisco)
- Cisco Medical Clinic, P.C.
- Kelly Coz Art
- Trinity Faith Dempsey, LMFT-A
- Jarred Kristian Donald, DDS
- Eastland Memorial Hospital District (Cisco Clinic)
- Eastland Memorial Hospital District (Avir at Cisco)
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 25, 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.