Provider Demographics
NPI:1679896534
Name:MALLORY, JARED CLARK (PT)
Entity type:Individual
Prefix:MR
First Name:JARED
Middle Name:CLARK
Last Name:MALLORY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3398 25TH STREET
Mailing Address - Street 2:
Mailing Address - City:PORT ARTHUR,
Mailing Address - State:TX
Mailing Address - Zip Code:77642
Mailing Address - Country:US
Mailing Address - Phone:409-985-9365
Mailing Address - Fax:409-985-6315
Practice Address - Street 1:3398 25TH STREET
Practice Address - Street 2:
Practice Address - City:PORT ARTHUR
Practice Address - State:TX
Practice Address - Zip Code:77642
Practice Address - Country:US
Practice Address - Phone:409-985-9365
Practice Address - Fax:409-985-6315
Is Sole Proprietor?:No
Enumeration Date:2010-03-08
Last Update Date:2010-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1137768225100000X, 225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner