Provider Demographics
NPI:1992950794
Name:CLARK, JAN ELLEN
Entity type:Individual
Prefix:
First Name:JAN
Middle Name:ELLEN
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8001 S ORANGE BLOSSOM TRL
Mailing Address - Street 2:FL MALL SUITE 692
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32809-7654
Mailing Address - Country:US
Mailing Address - Phone:407-859-7005
Mailing Address - Fax:407-850-2635
Practice Address - Street 1:3441 E COLONIAL DR
Practice Address - Street 2:STE F-32
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-5113
Practice Address - Country:US
Practice Address - Phone:407-206-5703
Practice Address - Fax:407-206-5704
Is Sole Proprietor?:No
Enumeration Date:2008-11-20
Last Update Date:2009-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAS4375237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist