Jeffry David Jeanetta Wark, MA LICSW

Primary specialty

Clinical Social WorkerTaxonomy code 1041C0700X

License

09459 Issued in MN

Practice address

1751 County Road B W Ste 100
Roseville, MN 55113-4037

Phone

(651) 698-0768

NPI assigned

Nov 20, 2006

Sex

Male

Sole proprietor

Yes

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

Specialties & licenses 1

Addresses

Other identifiers 2

Medicare fee-for-service enrollment

Enrolled in MN

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

Specialty

Clinical Social Worker

Education

Other, 1991

Medicare assignment

May accept Medicare assignment

Telehealth

Offers telehealth services

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

Credentials

Master of Arts

State licenses

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.

• Center for Integrated Well Being Inc

  • Clinical Social Worker
  • Saint Paul, MN
  • NPI 1053485003
  Medicare reassignment Authorized official

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

{
    "created_epoch": "1163980800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1521590400000",
    "number": "1982778932",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1751 COUNTY ROAD B W STE 100",
            "city": "ROSEVILLE",
            "state": "MN",
            "postal_code": "551134037",
            "telephone_number": "651-698-0768"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1751 COUNTY ROAD B W STE 100",
            "city": "ROSEVILLE",
            "state": "MN",
            "postal_code": "551134037",
            "telephone_number": "651-698-0768"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "JEANETTA WARK",
        "first_name": "JEFFRY",
        "middle_name": "DAVID",
        "name_prefix": "Mr.",
        "credential": "MA LICSW",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2006-11-20",
        "last_updated": "2018-03-21",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "MN",
            "license": "09459",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS",
            "identifier": "13GS2WA",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "VALUE OPTIONS",
            "identifier": "483889",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Emily Mann Jamison, MSW, LICSW
• Samuel Jang, MD
• Sarah Janus, OT
• Anna Jarvi, PTA, CLT
• Jason Wing Louie Chiropractic LLC
• Adam B Jeffers, MD
• Karol Jensen-Schneider
• Leif Erik Jensen, MD MPH
• Lisa Jenson
• Catherine M Jents, RN

• Clinical Social Worker in Roseville, MN
• Providers in Roseville, MN by specialty
• Clinical Social Worker in Minnesota

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 21, 2018; 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.