Provider Demographics
NPI:1174660054
Name:SHEPHERD, JENNIFER R (PT)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:R
Last Name:SHEPHERD
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1630 MILITARY CUTOFF RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-5719
Mailing Address - Country:US
Mailing Address - Phone:910-798-2318
Mailing Address - Fax:910-798-2319
Practice Address - Street 1:1630 MILITARY CUTOFF RD
Practice Address - Street 2:SUITE 110
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-5719
Practice Address - Country:US
Practice Address - Phone:910-798-2318
Practice Address - Fax:910-798-2319
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2016-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4865225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7211054Medicaid
NC017WJOtherBLUE CROSS BLUE SHIELD
NC562246243001OtherTRICARE
NC562099749OtherRPN
NCA6058OtherMEDCOST
NC232058OtherHUMANA
NC7211054Medicaid