Provider Demographics
NPI:1528606480
Name:SHEPPARD, JACOB IAN (DPT)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:IAN
Last Name:SHEPPARD
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 PLATINUM PT
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-4871
Mailing Address - Country:US
Mailing Address - Phone:407-206-4500
Mailing Address - Fax:407-643-2802
Practice Address - Street 1:701 PLATINUM PT
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-4871
Practice Address - Country:US
Practice Address - Phone:407-206-4500
Practice Address - Fax:407-643-2802
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-11
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT35253225100000X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist