MEDICARE: BARBARA JEAN 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	175T00000X	Peer Specialist

General Provider Information

NPI Number	:	1154906360
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BARBARA JEAN CLARK

Provider Business Mailing Address
First Line	:	3052 FAIR AVE
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43209-2229
Country	:	US
Telephone Number	:	614-517-2002
Fax Number	:

Provider Business Practice Location Address
First Line	:	3052 FAIR AVE
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43209-2229
Country	:	US
Telephone Number	:	614-517-2002
Fax Number	:

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

Provider Enumeration Date	:	03/10/2021
Last Update Date	:	03/10/2021

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Directions to “ BARBARA JEAN CLARK ” Practice Location

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