Provider Demographics
NPI:1831450733
Name:CLARK, JESSICA ANN (MA, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:ANN
Last Name:CLARK
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:MRS
Other - First Name:JESSICA
Other - Middle Name:ANN
Other - Last Name:KAMIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA,CCC-SLP
Mailing Address - Street 1:5818 STONE PINE TRL
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46033-8254
Mailing Address - Country:US
Mailing Address - Phone:317-625-3679
Mailing Address - Fax:
Practice Address - Street 1:7424 SHADELAND STATION WAY
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-3925
Practice Address - Country:US
Practice Address - Phone:317-288-7606
Practice Address - Fax:317-288-7607
Is Sole Proprietor?:No
Enumeration Date:2012-06-06
Last Update Date:2012-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22004331A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist