Provider Demographics
NPI:1720337876
Name:JEPSEN, MARY (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:JEPSEN
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 746722
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6722
Mailing Address - Country:US
Mailing Address - Phone:312-733-9730
Mailing Address - Fax:773-866-8014
Practice Address - Street 1:2301 N 29TH ST STE 500
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19132-3454
Practice Address - Country:US
Practice Address - Phone:215-444-7510
Practice Address - Fax:267-388-4659
Is Sole Proprietor?:No
Enumeration Date:2012-09-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2277482163W00000X, 363LP0808X
PARN699604163W00000X
PASP018290363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse