Provider Demographics
NPI:1841608221
Name:CLARK, JANE D (PA)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:D
Last Name:CLARK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JANE
Other - Middle Name:K
Other - Last Name:DIXON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:100 HOSPITAL LN STE 300
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46122-2000
Mailing Address - Country:US
Mailing Address - Phone:317-451-4639
Mailing Address - Fax:317-718-2476
Practice Address - Street 1:100 HOSPITAL LN STE 300
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IN
Practice Address - Zip Code:46122-2000
Practice Address - Country:US
Practice Address - Phone:317-451-4639
Practice Address - Fax:317-718-2476
Is Sole Proprietor?:No
Enumeration Date:2014-07-29
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10001703A363A00000X
IN10002256A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant