Provider Demographics
NPI:1841242369
Name:SHEPHERD, JENNET RUTH (OD)
Entity Type:Individual
Prefix:DR
First Name:JENNET
Middle Name:RUTH
Last Name:SHEPHERD
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 833
Mailing Address - Street 2:2500 US HWY 14
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53547-0833
Mailing Address - Country:US
Mailing Address - Phone:608-754-7411
Mailing Address - Fax:
Practice Address - Street 1:2500 E US HIGHWAY 14
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53545-0309
Practice Address - Country:US
Practice Address - Phone:608-754-7411
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2870-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38613900Medicaid
WI38613900Medicaid
WI87845Medicare ID - Type Unspecified