Provider Demographics
NPI:1407144926
Name:SHEPPARD, KASSONDRA JACKIE
Entity Type:Individual
Prefix:
First Name:KASSONDRA
Middle Name:JACKIE
Last Name:SHEPPARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2115 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95062-1663
Mailing Address - Country:US
Mailing Address - Phone:831-420-0120
Mailing Address - Fax:
Practice Address - Street 1:126 FRONT ST
Practice Address - Street 2:A
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-4402
Practice Address - Country:US
Practice Address - Phone:831-427-9343
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-18
Last Update Date:2011-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMEDI-CAL PRV NBRMedicaid
CA44AVOtherFS RES MHSS