Basic Information
| Provider Information | |||||||||
| NPI: | 1699323931 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | JESSE | ||||||||
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| Credential: | COTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 418 COUNCIL ST | ||||||||
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| City: | ANAMOSA | ||||||||
| State: | IA | ||||||||
| PostalCode: | 522054711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6087785587 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3485 WINDSOR AVE | ||||||||
| Address2: | |||||||||
| City: | DUBUQUE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 520011329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5635577180 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2019 | ||||||||
| LastUpdateDate: | 08/29/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.