Provider Demographics
NPI:1518137421
Name:SHEPHERD, JENNIFER LYNN (MSW, LICSW)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:SHEPHERD
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LYNN
Other - Last Name:RUTHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW, LICSW
Mailing Address - Street 1:4190 VINEWOOD LANE N
Mailing Address - Street 2:SUITE 111 PMB 403
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55442
Mailing Address - Country:US
Mailing Address - Phone:612-564-9355
Mailing Address - Fax:
Practice Address - Street 1:25 1ST AVE NE
Practice Address - Street 2:SUITE 100
Practice Address - City:BUFFALO
Practice Address - State:MN
Practice Address - Zip Code:55313
Practice Address - Country:US
Practice Address - Phone:763-682-3005
Practice Address - Fax:763-682-3006
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-06
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN168031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN071420000Medicaid
MN800002057Medicare Oscar/Certification