Healthcare Provider Details

I. General information

NPI: 1720337876
Provider Name (Legal Business Name): MARY JEPSEN PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2012
Last Update Date: 07/21/2022
Certification Date: 09/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 N 29TH ST STE 500
PHILADELPHIA PA
19132-3454
US

IV. Provider business mailing address

PO BOX 746722
ATLANTA GA
30374-6722
US

V. Phone/Fax

Practice location:
  • Phone: 215-444-7510
  • Fax: 267-388-4659
Mailing address:
  • Phone: 312-733-9730
  • Fax: 773-866-8014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN2277482
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN699604
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN2277482
License Number StateMA
# 4
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberSP018290
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: