MEDICARE: JAIME LEE 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	104100000X	Social Worker

General Provider Information

NPI Number	:	1467095745
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAIME LEE CLARK

Provider Business Mailing Address
First Line	:	429 MANOR DR
Second Line	:
City	:	EBENSBURG
State	:	PA
Zip	:	15931-4917
Country	:	US
Telephone Number	:	814-472-6060
Fax Number	:	814-472-1293

Provider Business Practice Location Address
First Line	:	1220 WAYNE AVE
Second Line	:
City	:	INDIANA
State	:	PA
Zip	:	15701-3514
Country	:	US
Telephone Number	:	724-464-2273
Fax Number	:

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

Provider Enumeration Date	:	10/19/2019
Last Update Date	:	10/19/2019

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Directions to “ JAIME LEE CLARK ” Practice Location

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