Provider Demographics
NPI:1790168201
Name:SHEPPARD, JENNIFER (MSW, LICSW)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:SHEPPARD
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:HALDA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:413 SE 13TH ST
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-0015
Mailing Address - Country:US
Mailing Address - Phone:218-999-9908
Mailing Address - Fax:218-999-9959
Practice Address - Street 1:413 SE 13TH ST
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-0015
Practice Address - Country:US
Practice Address - Phone:218-999-9908
Practice Address - Fax:218-999-9959
Is Sole Proprietor?:No
Enumeration Date:2015-07-01
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN219411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical