Provider Demographics
NPI:1689649857
Name:SHEPPARD, JEANETTA (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:JEANETTA
Middle Name:
Last Name:SHEPPARD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 ANDREWS AVE.
Mailing Address - Street 2:
Mailing Address - City:FORT RUCKER
Mailing Address - State:AL
Mailing Address - Zip Code:36362-5105
Mailing Address - Country:US
Mailing Address - Phone:334-255-7918
Mailing Address - Fax:334-255-7617
Practice Address - Street 1:301 ANDREWS AVENUE
Practice Address - Street 2:UNITED STATES ARMY SUBSTANCE ABUSE PROGRAM
Practice Address - City:FORT RUCKER
Practice Address - State:AL
Practice Address - Zip Code:36362-5105
Practice Address - Country:US
Practice Address - Phone:334-255-7918
Practice Address - Fax:334-255-7617
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCAP867101YA0400X
FLICADC6435101YA0400X
FLSW72541041C0700X
AL2027C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)