Provider Demographics
NPI:1649280983
Name:SHEPPARD, JERRY M (MD)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:M
Last Name:SHEPPARD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 N STATE ST
Mailing Address - Street 2:HOSPITALIST
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-6426
Mailing Address - Fax:601-984-6439
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:DEPT OF MEDICINE DIVISION OF GENERAL INTERNAL MEDICINE
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39225-4146
Practice Address - Country:US
Practice Address - Phone:601-984-2746
Practice Address - Fax:601-984-6870
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2014-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS18932207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS154127Medicaid
MS06356838Medicaid
MS06356838Medicaid
MS154127Medicaid
MSP00771086Medicare PIN
MS110002049Medicare PIN
MS302I115857Medicare PIN
MSP01200715Medicare PIN