Provider Demographics
NPI:1518682830
Name:SHEPHERD, JENNIFER (RN)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:SHEPHERD
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:932 E 113 N
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-5119
Mailing Address - Country:US
Mailing Address - Phone:208-970-4079
Mailing Address - Fax:
Practice Address - Street 1:932 E 113 N
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-5119
Practice Address - Country:US
Practice Address - Phone:208-970-4079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-10
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID51454163WN1003X, 163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WH0200XNursing Service ProvidersRegistered NurseHome HealthGroup - Single Specialty
No163WN1003XNursing Service ProvidersRegistered NurseNutrition Support