Provider Demographics
NPI:1891965000
Name:SHEPHERD, JESSIE ROSE (MFTI)
Entity Type:Individual
Prefix:
First Name:JESSIE
Middle Name:ROSE
Last Name:SHEPHERD
Suffix:
Gender:F
Credentials:MFTI
Other - Prefix:
Other - First Name:JESSIE
Other - Middle Name:ROSE
Other - Last Name:GREENE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MFTI
Mailing Address - Street 1:1266 14TH ST.
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609
Mailing Address - Country:US
Mailing Address - Phone:510-867-0963
Mailing Address - Fax:
Practice Address - Street 1:7680 ELPHICK RD
Practice Address - Street 2:
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472-4751
Practice Address - Country:US
Practice Address - Phone:707-543-6478
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-04
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health