MEDICARE: MRS. JEANETTA SHEPPARD LCSW

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	CAP867	FL
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	ICADC6435	FL
3	1041C0700X	Clinical Social Worker	SW7254	FL
4	1041C0700X	Clinical Social Worker	2027C	AL

General Provider Information

NPI Number	:	1689649857
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JEANETTA SHEPPARD LCSW

Provider Business Mailing Address
First Line	:	301 ANDREWS AVE.
Second Line	:
City	:	FORT RUCKER
State	:	AL
Zip	:	36362-5105
Country	:	US
Telephone Number	:	334-255-7918
Fax Number	:	334-255-7617

Provider Business Practice Location Address
First Line	:	301 ANDREWS AVENUE
Second Line	:	UNITED STATES ARMY SUBSTANCE ABUSE PROGRAM
City	:	FORT RUCKER
State	:	AL
Zip	:	36362-5105
Country	:	US
Telephone Number	:	334-255-7918
Fax Number	:	334-255-7617

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

Provider Enumeration Date	:	02/21/2006
Last Update Date	:	06/18/2012

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