1437335551 NPI number — JENNIFER M. CLARK R.N., FNP, PMHNP

Table of content: DR. ADETOKUNBO A LADENIKA M.D (NPI 1306030143)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437335551 NPI number — JENNIFER M. CLARK R.N., FNP, PMHNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARK
Provider First Name:
JENNIFER
Provider Middle Name:
M.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
R.N., FNP, PMHNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1437335551
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/08/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3114 CARVEL DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANTA ROSA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95405-7062
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-757-3117
Provider Business Mailing Address Fax Number:
707-303-2694

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 DOYLE PARK DR STE G04
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANTA ROSA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95405-4559
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-303-8349
Provider Business Practice Location Address Fax Number:
707-303-2694
Provider Enumeration Date:
01/18/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  740722 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: NP12069 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 193487901 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8Y5099 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: P00622287 . This is a "RR MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".