Jacob Clark, APRN, PMHNP-BC

Primary specialty

Psychiatric/Mental Health Nurse PractitionerTaxonomy code 363LP0808X

License

8480668-4405 Issued in UT

Practice address

138 E 12300 S Unit 860
Draper, UT 84020-7976

Phone

(801) 449-1429

NPI assigned

May 3, 2016

Reactivated

Sep 29, 2022

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Electronic endpoints 1

Medicare fee-for-service enrollment

Enrolled in UT, CO2 enrollments

Eligible to order & refer

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

Green means eligible to order or refer.

Enrollment records 2

Specialty

Nurse Practitioner

Education

Vanderbilt University School of Medicine, 2022

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Telehealth

Offers telehealth services

Group practices

Ihc Health Services IncGroup PAC ID 1850209420, 3,948 clinicians

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

Credentials

Nurse Practitioner

Practice roles

Locations

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.

• Ihc Health Services Inc

  • Multi-Specialty Clinic/Center
  • Sandy, UT
  • NPI 1942325154
  Medicare reassignment Care Compare group NPD
• Iron Phoenix Psychiatry, LLC

  • Psychiatric/Mental Health Nurse Practitioner
  • Draper, UT
  • NPI 1255055158
  NPD Authorized official
• Intermountain Medical Group Denver, LLC

  • Family Medicine Physician
  • Denver, CO
  • NPI 1083021083
  Medicare reassignment
• Ihc Health Services Inc

  dba McKay Dee Physical Medicine and Rehab

  • Physical Medicine & Rehabilitation Physician
  • Ogden, UT
  • NPI 1972274850
  NPD
• Ihc Health Services, Inc.

  dba St George Adolescent Partial Hospitalization

  • Psychiatry Physician
  • St George, UT
  • NPI 1023843844
  NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1462233600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1664582400000",
    "number": "1487009957",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "138 E 12300 S UNIT 860",
            "city": "DRAPER",
            "state": "UT",
            "postal_code": "840207976"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "138 E 12300 S UNIT 860",
            "city": "DRAPER",
            "state": "UT",
            "postal_code": "840207976",
            "telephone_number": "801-449-1429"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "CLARK",
        "first_name": "JACOB",
        "credential": "APRN, PMHNP-BC",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2016-05-03",
        "last_updated": "2022-10-01",
        "certification_date": "2022-10-01",
        "deactivation_date": "2022-09-20",
        "reactivation_date": "2022-09-29",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "247200000X",
            "taxonomy_group": "",
            "desc": "Technician, Other",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363LP0808X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Psychiatric/Mental Health",
            "state": "UT",
            "license": "8480668-4405",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "CONNECT",
            "endpointTypeDescription": "CONNECT URL",
            "endpoint": "ironphoenixpsych@gmail.com",
            "affiliation": "N",
            "use": "DIRECT",
            "useDescription": "Direct",
            "address_1": "138 E 12300 S Unit 860",
            "city": "Draper",
            "state": "UT",
            "country_code": "US",
            "postal_code": "840207976",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

• Cilantro Holdings, LLC (One Care Hospice)
• Ana Cisneros
• Renae Elizabeth Claar, LCSW
• Garrrek Linden Clark, PHARMD
• Genevieve Clark
• Daniel B Clayton, MD
• Ellie Clayton
• Anna Clegg
• Gina Marie Clerico, M.A., CCC-SLP
• Jillian Cluff I

• Psychiatric/Mental Health Nurse Practitioner in Draper, UT
• Providers in Draper, UT by specialty
• Psychiatric/Mental Health Nurse Practitioner in Utah

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 1, 2022; 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.