MEDICARE: REVA JO SHEPPARD L.P.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	67149	TX

General Provider Information

NPI Number	:	1396095469
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	REVA JO SHEPPARD L.P.C.

Provider Business Mailing Address
First Line	:	1533 MERRIMAC CIR
Second Line	:	SUITE 101
City	:	FORT WORTH
State	:	TX
Zip	:	76107-6506
Country	:	US
Telephone Number	:	817-810-0030
Fax Number	:	817-877-3562

Provider Business Practice Location Address
First Line	:	1533 MERRIMAC CIR
Second Line	:	SUITE 101
City	:	FORT WORTH
State	:	TX
Zip	:	76107-6506
Country	:	US
Telephone Number	:	817-810-0030
Fax Number	:	817-877-3562

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/14/2012
Last Update Date	:	09/14/2012

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