Provider Demographics
NPI:1851045793
Name:SHEPHERD, JADE LEANDRIA (PT, DPT)
Entity Type:Individual
Prefix:
First Name:JADE
Middle Name:LEANDRIA
Last Name:SHEPHERD
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:753 JEFFERSON HWY
Mailing Address - Street 2:
Mailing Address - City:MOUTH OF WILSON
Mailing Address - State:VA
Mailing Address - Zip Code:24363-3818
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:574 E MAIN ST
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:VA
Practice Address - Zip Code:24348-3879
Practice Address - Country:US
Practice Address - Phone:276-773-8118
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-09
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305214859225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist