MEDICARE: ANDREA JANA CLARK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician	9371119383	IN

General Provider Information

NPI Number	:	1003778895
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREA JANA CLARK

Provider Business Mailing Address
First Line	:	3920 ZEENAT DR
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46254-3135
Country	:	US
Telephone Number	:	317-300-3938
Fax Number	:

Provider Business Practice Location Address
First Line	:	3920 ZEENAT DR
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46254-3135
Country	:	US
Telephone Number	:	317-300-3938
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/01/2025
Last Update Date	:	12/01/2025

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