Individual
JACKSON TYLER CLARK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
6985 W 38TH ST STE 100, INDIANAPOLIS, IN 46254-3918
(317) 243-0028
Mailing address
8614 WESTWOOD CENTER DR FL 9, VIENNA, VA 22182-2442
(703) 847-8899
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
18004592A
IN
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Enumeration date
05/21/2025
Last updated
07/24/2025
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