Provider Demographics
NPI:1598112054
Name:SHEPHERD, JASON NATHANIEL (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:NATHANIEL
Last Name:SHEPHERD
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16838 PLEASANT BEACH DR SE
Mailing Address - Street 2:
Mailing Address - City:YELM
Mailing Address - State:WA
Mailing Address - Zip Code:98597-8561
Mailing Address - Country:US
Mailing Address - Phone:360-894-8953
Mailing Address - Fax:
Practice Address - Street 1:727 N TOWER AVE
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-4754
Practice Address - Country:US
Practice Address - Phone:360-557-2027
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-14
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60807187363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant