Provider Demographics
NPI:1184887150
Name:SANDERS, MARY JO (RN, LCSW)
Entity type:Individual
Prefix:MS
First Name:MARY JO
Middle Name:
Last Name:SANDERS
Suffix:
Gender:F
Credentials:RN, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 N 33RD ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97478-5838
Mailing Address - Country:US
Mailing Address - Phone:541-746-7732
Mailing Address - Fax:
Practice Address - Street 1:1651 CENTENNIAL BLVD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-3363
Practice Address - Country:US
Practice Address - Phone:541-762-4551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-09
Last Update Date:2016-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL37211041C0700X
OR000035076RN163WC0400X
OR00035076RN163WM0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163WM0102XNursing Service ProvidersRegistered NurseMaternal Newborn