Jennifer A Clark, LCSW

Primary specialty

Clinical Social WorkerTaxonomy code 1041C0700X

License

ASW19290 Issued in CA

Practice address

1301 Southpoint Blvd
Petaluma, CA 94954-6867

Phone

(707) 559-7500

Fax

(707) 559-7540

NPI assigned

Oct 13, 2010

Sex

Female

Sole proprietor

No

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

Specialties & licenses 1

Addresses

Electronic endpoints 1

Medicare fee-for-service enrollment

Enrolled in CA

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

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.

• Permanente Medical Group Inc

  • Internal Medicine Physician
  • Santa Clara, CA
  • NPI 1073606299
  Medicare reassignment NPD

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

{
    "created_epoch": "1286928000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1640822400000",
    "number": "1770893786",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1301 SOUTHPOINT BLVD",
            "city": "PETALUMA",
            "state": "CA",
            "postal_code": "949546867",
            "telephone_number": "707-559-7500",
            "fax_number": "707-559-7540"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1301 SOUTHPOINT BLVD",
            "city": "PETALUMA",
            "state": "CA",
            "postal_code": "949546867",
            "telephone_number": "707-559-7500",
            "fax_number": "707-559-7540"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "CLARK",
        "first_name": "JENNIFER",
        "middle_name": "A",
        "credential": "LCSW",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2010-10-13",
        "last_updated": "2021-12-30",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "CA",
            "license": "ASW19290",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "SOAP",
            "endpointTypeDescription": "SOAP URL",
            "endpoint": "https://careepicwest.kp.org:14430/Interconnect-prodcalgateway/wcf/epic.community.hie/xcpdrespondinggatewaysync.svc/ncalceq",
            "affiliation": "Y",
            "endpointDescription": "Carequality",
            "affiliationName": "The Permanente Medical Group",
            "use": "HIE",
            "useDescription": "Health Information Exchange (HIE)",
            "contentType": "OTHER",
            "contentTypeDescription": "Other",
            "contentOtherDescription": "C-CDA",
            "address_1": "3559 Round Barn Blvd",
            "city": "Santa Rosa",
            "state": "CA",
            "country_code": "US",
            "postal_code": "954031763",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

• Michelle Rose Ciaravella, L.P.N.
• Cinnabar School District
• City of Petaluma Ambulance Service
• Civileyes LLC
• Ashley Michelle Clark
• Julie D Clark, MD
• Margaret Liberty Clark
• Robert L. Clark, PT
• Amanda Ramona Clay
• Renisha R Clay

• Clinical Social Worker in Petaluma, CA
• Providers in Petaluma, CA by specialty
• Clinical Social Worker in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 30, 2021; 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.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.