Provider Demographics
NPI:1609656289
Name:SHEPARD, MARY JO BEVERLY
Entity Type:Individual
Prefix:
First Name:MARY JO
Middle Name:BEVERLY
Last Name:SHEPARD
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 1:9013 CHIPPEWA TRL
Mailing Address - Street 2:
Mailing Address - City:EVART
Mailing Address - State:MI
Mailing Address - Zip Code:49631-9350
Mailing Address - Country:US
Mailing Address - Phone:810-908-2006
Mailing Address - Fax:
Practice Address - Street 1:207 N FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-2303
Practice Address - Country:US
Practice Address - Phone:989-824-2374
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-02
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401011545101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health