Healthcare Provider Details

I. General information

NPI: 1821888249
Provider Name (Legal Business Name): AGAPE CLINIC WITH HEART: A PROFESSIONAL NURSING ORGANIZATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2025
Last Update Date: 05/08/2025
Certification Date: 05/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3114 CARVEL DR
SANTA ROSA CA
95405-7062
US

IV. Provider business mailing address

3114 CARVEL DR
SANTA ROSA CA
95405-7062
US

V. Phone/Fax

Practice location:
  • Phone: 707-757-3117
  • Fax:
Mailing address:
  • Phone: 707-757-3117
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER MARIE CLARK
Title or Position: NURSE PRACTITIONER, PRESIDENT
Credential: FNP-BC, PMHNP-BC
Phone: 707-757-3117