Provider Demographics
NPI:1205036357
Name:MATTO-SHEPARD, JIMMY LEE (PHD)
Entity Type:Individual
Prefix:
First Name:JIMMY
Middle Name:LEE
Last Name:MATTO-SHEPARD
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 BODEGA AVE
Mailing Address - Street 2:SUITE #4
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952-2666
Mailing Address - Country:US
Mailing Address - Phone:707-762-1670
Mailing Address - Fax:
Practice Address - Street 1:1 BODEGA AVE
Practice Address - Street 2:SUITE #4
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-2666
Practice Address - Country:US
Practice Address - Phone:707-762-1670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-18
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY15031103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist