Healthcare Provider Details

I. General information

NPI: 1184887150
Provider Name (Legal Business Name): MARY JO SANDERS RN, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2008
Last Update Date: 02/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1651 CENTENNIAL BLVD
SPRINGFIELD OR
97477-3363
US

IV. Provider business mailing address

310 N 33RD ST
SPRINGFIELD OR
97478-5838
US

V. Phone/Fax

Practice location:
  • Phone: 541-762-4551
  • Fax:
Mailing address:
  • Phone: 541-746-7732
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL3721
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number000035076RN
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code163WM0102X
TaxonomyMaternal Newborn Registered Nurse
License Number00035076RN
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: