Provider Demographics
NPI:1386030146
Name:SHEARD, JASON DEAN (AGACNP-BC)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:DEAN
Last Name:SHEARD
Suffix:
Gender:M
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12809 THOMAS JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:MANOR
Mailing Address - State:TX
Mailing Address - Zip Code:78653-3921
Mailing Address - Country:US
Mailing Address - Phone:936-645-0166
Mailing Address - Fax:
Practice Address - Street 1:1514 JEFFERSON HWY
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70121-2429
Practice Address - Country:US
Practice Address - Phone:504-842-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-08
Last Update Date:2015-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP08210363LA2100X
TXAP126886363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2390741Medicaid
MS07750381Medicaid
LA412342YH3UMedicare PIN