Healthcare Provider Details

I. General information

NPI: 1720105398
Provider Name (Legal Business Name): MARY LOUISE JEPPSEN MHPP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 12/05/2024
Certification Date: 12/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4321 BOULEVARD PARK S
MOBILE AL
36609-3404
US

IV. Provider business mailing address

417 ADMIRAL SEMMES AVE
DAUPHIN ISLAND AL
36528-4551
US

V. Phone/Fax

Practice location:
  • Phone: 479-981-1062
  • Fax:
Mailing address:
  • Phone: 479-981-1065
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberP1002017
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: