Provider Demographics
NPI:1578850376
Name:MOODIE-SHEPHERD, JESSIE DAWN (NP)
Entity Type:Individual
Prefix:
First Name:JESSIE
Middle Name:DAWN
Last Name:MOODIE-SHEPHERD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 PENN PLZ
Mailing Address - Street 2:8TH FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10119-0002
Mailing Address - Country:US
Mailing Address - Phone:646-761-1725
Mailing Address - Fax:
Practice Address - Street 1:1 PENN PLZ
Practice Address - Street 2:8TH FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10119-0002
Practice Address - Country:US
Practice Address - Phone:646-761-1725
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-30
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF336664363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily