Jacquelyn Mae Block, MFT, LCSW, LMFT

Primary specialty

Clinical Social WorkerTaxonomy code 1041C0700X

License

2841-123 Issued in WI

Practice address

430 E Division St
Fond Du Lac, WI 54935-4560

Phone

(920) 926-4209

NPI assigned

May 2, 2007

Sex

Female

Sole proprietor

No

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Agnesian Healthcare, Inc

  • General Acute Care Hospital
  • Fond Du Lac, WI
  • NPI 1346228541

  WI

  Medicare reassignment Care Compare group NPD
• Agnesian Healthcare Inc

  • Community/Retail Pharmacy
  • Waupun, WI
  • NPI 1366417917
  Care Compare group NPD
• Agnesian Healthcare Inc

  • Durable Medical Equipment & Medical Supplies
  • Ripon, WI
  • NPI 1073842571
  Care Compare group
• Agnesian Healthcare Inc

  • Durable Medical Equipment & Medical Supplies
  • Fond Du Lac, WI
  • NPI 1083676217
  Care Compare group
• Agnesian Healthcare Inc

  • Community/Retail Pharmacy
  • Fond Du Lac, WI
  • NPI 1104891746
  Care Compare group
• Agnesian Healthcare Inc

  • Durable Medical Equipment & Medical Supplies
  • Ripon, WI
  • NPI 1316212954
  Care Compare group
• Agnesian Healthcare Inc

  • Community/Retail Pharmacy
  • Fond Du Lac, WI
  • NPI 1326013962
  Care Compare group
• Agnesian Healthcare Inc

  • Durable Medical Equipment & Medical Supplies
  • Fond Du Lac, WI
  • NPI 1437110988
  Care Compare group
• Agnesian Healthcare Inc

  • Durable Medical Equipment & Medical Supplies
  • N Fond Du Lac, WI
  • NPI 1679516454
  Care Compare group
• Agnesian Healthcare Inc

  • Durable Medical Equipment & Medical Supplies
  • Fond Du Lac, WI
  • NPI 1689610735
  Care Compare group
• Agnesian Healthcare Inc

  • Durable Medical Equipment & Medical Supplies
  • Waupun, WI
  • NPI 1750326203
  Care Compare group
• Agnesian Healthcare Inc

  • Durable Medical Equipment & Medical Supplies
  • Campbellsport, WI
  • NPI 1922069194
  Care Compare group

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

• Agnesian Healthcare, Inc

  • General Acute Care Hospital
  • Fond Du Lac, WI
  • NPI 1346228541

  Hospital

  Care Compare affiliation

Specialty

Clinical Social Worker

Education

Other, 1990

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Telehealth

Offers telehealth services

Group practices

Agnesian Healthcare Inc 392 clinicians

Practice addresses (Care Compare)

Hospital & facility affiliations

• SSM Health St Agnes Hospital-Fond Du Lac Hospital, Fond Du Lac, WI, CCN 520088

Medicare fee-for-service enrollment

Enrolled in WI

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: No
• Power mobility devices: No
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Locations

The complete NPPES record for this NPI in the NPI Registry API format, last updated by the provider on Dec 16, 2020.

{
    "created_epoch": "1178064000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1608076800000",
    "number": "1336360429",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "420 E DIVISION ST",
            "city": "FOND DU LAC",
            "state": "WI",
            "postal_code": "549354560",
            "telephone_number": "920-926-4209"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "430 E DIVISION ST",
            "city": "FOND DU LAC",
            "state": "WI",
            "postal_code": "549354560",
            "telephone_number": "920-926-4209"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "BLOCK",
        "first_name": "JACQUELYN",
        "middle_name": "MAE",
        "name_prefix": "Ms.",
        "credential": "MFT, LCSW, LMFT",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2007-05-02",
        "last_updated": "2020-12-16",
        "certification_date": "2020-12-16",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "106H00000X",
            "taxonomy_group": "",
            "desc": "Marriage & Family Therapist",
            "state": "WI",
            "license": "226-124",
            "primary": false
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "WI",
            "license": "2841-123",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "LMFT",
            "identifier": "226-124",
            "state": "WI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "LCSW",
            "identifier": "2841-123",
            "state": "WI"
        }
    ],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "jblock330880@direct-ehr-ssmhc.com",
            "affiliation": "N",
            "use": "DIRECT",
            "useDescription": "Direct",
            "contentType": "OTHER",
            "contentTypeDescription": "Other",
            "contentOtherDescription": "jblock330880@direct-ehr-ssmhc.com",
            "address_1": "430 E Division St",
            "city": "Fond Du Lac",
            "state": "WI",
            "country_code": "US",
            "postal_code": "549354560",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "endpointType": "FHIR",
            "endpointTypeDescription": "FHIR URL",
            "endpoint": "https://fhir.ssmhc.com/fhir/api/FHIR/DSTU2/",
            "affiliation": "N",
            "use": "OTHER",
            "useDescription": "Other",
            "useOtherDescription": "FHIR API",
            "contentType": "OTHER",
            "contentTypeDescription": "Other",
            "contentOtherDescription": "CCD",
            "address_1": "430 E Division St",
            "city": "Fond Du Lac",
            "state": "WI",
            "country_code": "US",
            "postal_code": "549354560",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

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• All providers in Fond Du Lac, WI
• Clinical Social Worker in Wisconsin

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 16, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.