Provider Demographics
NPI:1356947618
Name:SHEPHERD, JORDAN
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:SHEPHERD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 TOLL GATE RD
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886-2717
Mailing Address - Country:US
Mailing Address - Phone:401-477-9495
Mailing Address - Fax:
Practice Address - Street 1:600 TOLL GATE RD
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02886-2717
Practice Address - Country:US
Practice Address - Phone:401-477-9495
Practice Address - Fax:401-205-3582
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-10
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
RILBA00238103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI1013505676Medicaid