| Doctor Name: | JUSTIN CLARK |
| NPI Number: | 1013286863 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | LMT |
| License Number: | 18505 |
| Business Practice Address: | 12923 Nw Cornell Rd #201 Portland, OR - 972295834 |
| Business Phone Number: | 5036463393 |
| Business Fax Number: | |
| Mailing Address: | 12923 Nw Cornell Rd, #201 PORTLAND |
| State: | OR |
| Postal Code: | 972295834 |
| Phone Number: | 5036463393 |
| Fax Number: | |
| NPI Enumeration Date: | 12/23/2011 |
| NPI Last Update Date: | 12/23/2011 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 225700000X |
| License Number: | 18505 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | OR |
| Taxonomy Type: | Respiratory, Developmental, Rehabilitative and Restorative Service Providers |
| Taxonomy Classification: | Massage Therapist |
| Taxonomy Specialization: | |
| Taxonomy Definition: | An individual trained in the manipulation of tissues (as by rubbing, stroking, kneading, or tapping) with the hand or an instrument for remedial or hygienic purposes. |