Provider Demographics
NPI:1275769341
Name:SHEPHERD, JEREMY M (ATC)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:M
Last Name:SHEPHERD
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:947 CROSS ST
Mailing Address - Street 2:APT. 2
Mailing Address - City:CALIFORNIA
Mailing Address - State:PA
Mailing Address - Zip Code:15419-1495
Mailing Address - Country:US
Mailing Address - Phone:703-994-8433
Mailing Address - Fax:
Practice Address - Street 1:250 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:CALIFORNIA
Practice Address - State:PA
Practice Address - Zip Code:15419-1341
Practice Address - Country:US
Practice Address - Phone:724-938-4342
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-03
Last Update Date:2009-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART0045082255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer