Provider Demographics
NPI:1083162382
Name:SHEPPARD, JORDAN
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:SHEPPARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 ETERNITY CT
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20874-6103
Mailing Address - Country:US
Mailing Address - Phone:240-750-9495
Mailing Address - Fax:
Practice Address - Street 1:5 ETERNITY CT
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:MD
Practice Address - Zip Code:20874-6103
Practice Address - Country:US
Practice Address - Phone:240-750-9495
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-14
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer