Healthcare Provider Details

I. General information

NPI: 1215507298
Provider Name (Legal Business Name): JEFFREY MICHAEL CLEMENS ACNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2021
Last Update Date: 07/21/2021
Certification Date: 07/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 COFFEE RD
MODESTO CA
95355-2803
US

IV. Provider business mailing address

1700 COFFEE RD
MODESTO CA
95355-2803
US

V. Phone/Fax

Practice location:
  • Phone: 209-579-5628
  • Fax: 209-579-5637
Mailing address:
  • Phone: 209-526-4500
  • Fax: 209-579-5637

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number95017564
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: