Provider Demographics
NPI:1881077493
Name:SHEPHERD, JEFFERY (LMT, MMP)
Entity type:Individual
Prefix:
First Name:JEFFERY
Middle Name:
Last Name:SHEPHERD
Suffix:
Gender:M
Credentials:LMT, MMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1435 FIVE MILE DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75216-6977
Mailing Address - Country:US
Mailing Address - Phone:678-654-6522
Mailing Address - Fax:
Practice Address - Street 1:718 W ARAPAHO RD
Practice Address - Street 2:SUITE 100
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75080-4160
Practice Address - Country:US
Practice Address - Phone:678-654-6522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-30
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT115996225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist