MEDICARE: JAJUANA K LARK RBT

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	106S00000X	AZ

General Provider Information

NPI Number	:	1508704487
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAJUANA K LARK RBT

Provider Business Mailing Address
First Line	:	105 N BEEBE ST APT 2025
Second Line	:
City	:	GILBERT
State	:	AZ
Zip	:	85234-7687
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	11225 N 28TH DR STE C202
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85029-5600
Country	:	US
Telephone Number	:	480-953-3888
Fax Number	:

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

Provider Enumeration Date	:	03/23/2026
Last Update Date	:	03/23/2026

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Directions to “ JAJUANA K LARK RBT” Practice Location

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