Jack J Clark, D.C.

Primary specialty

ChiropractorTaxonomy code 111N00000X

License

08000717A Issued in IN

Practice address

6015 E State Blvd
Fort Wayne, IN 46815-7638

Phone

(260) 486-1886

NPI assigned

Dec 12, 2005

Sex

Male

Sole proprietor

Yes

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

Specialties & licenses 1

Addresses

Other identifiers 2

Medicare fee-for-service enrollment

Enrolled in IN

Enrollment records 1

Specialty

Chiropractic

Education

Western States College of Chiropractic, 1980

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

Practice roles

Locations

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.

• Jack J. Clark, D.C.P.C.

  • Chiropractor
  • Fort Wayne, IN
  • NPI 1083820302
  Medicare reassignment NPD
• The Chiropractic Rehabilitation and Wellness Center, Inc

  • Rehabilitation Chiropractor
  • Fort Wayne, IN
  • NPI 1174714448
  NPD (past)

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

{
    "created_epoch": "1134345600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1277164800000",
    "number": "1902881014",
    "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"
        },
        {
            "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": {
        "last_name": "CLARK",
        "first_name": "JACK",
        "middle_name": "J",
        "name_prefix": "Dr.",
        "credential": "D.C.",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2005-12-12",
        "last_updated": "2010-06-22",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "111N00000X",
            "taxonomy_group": "",
            "desc": "Chiropractor",
            "state": "IN",
            "license": "08000717A",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "100289660A",
            "state": "IN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS/BLUE SHIELD",
            "identifier": "000000086699",
            "state": "IN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• David W Clark, M.D.
• Erin D Clark, ATC
• Gabrielle Breann Clark
• Gail A Clark, CNM
• Grace Xinxing Clark, DDS
• Kira Melissa Clark, MS, BCBA
• Lauren Elizabeth Clark
• Mackenzie Marie Clark, MS, LAT, ATC
• McKenzie Clark
• Melanie Clark

• 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 22, 2010; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.