Provider Demographics
NPI:1659984326
Name:SHEPPARD, JASON P (LMSW- CLINICAL)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:P
Last Name:SHEPPARD
Suffix:
Gender:M
Credentials:LMSW- CLINICAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50258 VAN DYKE AVE STE A
Mailing Address - Street 2:
Mailing Address - City:SHELBY TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48317-1374
Mailing Address - Country:US
Mailing Address - Phone:586-884-4714
Mailing Address - Fax:
Practice Address - Street 1:50258 VAN DYKE AVE STE A
Practice Address - Street 2:
Practice Address - City:SHELBY TWP
Practice Address - State:MI
Practice Address - Zip Code:48317-1374
Practice Address - Country:US
Practice Address - Phone:585-884-4714
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-24
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011174371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty