Provider Demographics
NPI:1417342601
Name:SHEPARD, JENNIFER KAYE (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:KAYE
Last Name:SHEPARD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CPG INTERNAL MEDICINE
Mailing Address - Street 2:2825 FORT MISSOULA ROAD, BUILDING 1, SUITE 217
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59804
Mailing Address - Country:US
Mailing Address - Phone:406-327-3850
Mailing Address - Fax:
Practice Address - Street 1:2875 TINA AVE STE 102
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59808-1582
Practice Address - Country:US
Practice Address - Phone:406-272-3746
Practice Address - Fax:406-303-3308
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-03
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
UT10104230-1205207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT10104230-1205OtherLICENSE NUMBER
UT10104230-8905OtherCS LICENSE NUMBER