Provider Demographics
NPI:1508566910
Name:SHEPARD, KELAJAH
Entity Type:Individual
Prefix:
First Name:KELAJAH
Middle Name:
Last Name:SHEPARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2847 TEASLEY DR
Mailing Address - Street 2:
Mailing Address - City:PEARL
Mailing Address - State:MS
Mailing Address - Zip Code:39208-5849
Mailing Address - Country:US
Mailing Address - Phone:601-278-6796
Mailing Address - Fax:
Practice Address - Street 1:2847 TEASLEY DR
Practice Address - Street 2:
Practice Address - City:PEARL
Practice Address - State:MS
Practice Address - Zip Code:39208-5849
Practice Address - Country:US
Practice Address - Phone:601-278-6796
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-06
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
374J00000X, 172V00000X
MS174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator
No374J00000XNursing Service Related ProvidersDoula
No172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME568946544OtherBCBS
5874OtherHEALTH PARTNERS
MS236Medicaid