Provider Demographics
NPI:1134944788
Name:SHEPHERD, JEREMY DOUGLAS
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:DOUGLAS
Last Name:SHEPHERD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:651 DUNLOP LN
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37040-5015
Mailing Address - Country:US
Mailing Address - Phone:931-502-1000
Mailing Address - Fax:
Practice Address - Street 1:651 DUNLOP LN
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37040-5015
Practice Address - Country:US
Practice Address - Phone:931-502-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-19
Last Update Date:2025-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
146L00000X
TN259150163W00000X
TN37981363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, Paramedic
No163W00000XNursing Service ProvidersRegistered Nurse