Provider Demographics
NPI:1346466935
Name:ATHERTON, MARY JO (RN, PMHNP)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:JO
Last Name:ATHERTON
Suffix:
Gender:F
Credentials:RN, PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2250 D ST NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-2768
Mailing Address - Country:US
Mailing Address - Phone:503-364-6093
Mailing Address - Fax:503-364-5121
Practice Address - Street 1:2250 D ST NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-2768
Practice Address - Country:US
Practice Address - Phone:503-364-6093
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200750154NP363LP0808X
OR090006687RN163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse