Provider Demographics
NPI:1114683802
Name:SHEPPARD, JACLYN ADISON
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:ADISON
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 1:713 SW 157TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73170-7688
Mailing Address - Country:US
Mailing Address - Phone:405-821-2293
Mailing Address - Fax:
Practice Address - Street 1:2625 GENERAL PERSHING BLVD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73107-6437
Practice Address - Country:US
Practice Address - Phone:405-942-6210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-17
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator