Provider Demographics
NPI:1275622011
Name:SHEPHERD, JAY R (PT)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:R
Last Name:SHEPHERD
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19851 OBSERVATION DR STE 450
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20876-4148
Mailing Address - Country:US
Mailing Address - Phone:301-977-6777
Mailing Address - Fax:301-977-0108
Practice Address - Street 1:19851 OBSERVATION DR STE 450
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:MD
Practice Address - Zip Code:20876-4148
Practice Address - Country:US
Practice Address - Phone:301-977-6777
Practice Address - Fax:301-977-0108
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD172232251X0800X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC101162P53Medicare PIN