Provider Demographics
NPI:1720064223
Name:SHEPHERD, JENNIFER (APN)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:SHEPHERD
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 BOGY AVE
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:AR
Mailing Address - Zip Code:72601-6706
Mailing Address - Country:US
Mailing Address - Phone:870-743-9365
Mailing Address - Fax:
Practice Address - Street 1:502 WEST COURT STREET.
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:AR
Practice Address - Zip Code:72641
Practice Address - Country:US
Practice Address - Phone:870-446-2203
Practice Address - Fax:870-446-2206
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2012-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA01229363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR135650758Medicaid
AR5T172Medicare ID - Type Unspecified