Provider Demographics
NPI:1912160797
Name:SHEPHERD, JESSICA A (MD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:A
Last Name:SHEPHERD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5600 W LOVERS LN STE 100
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75209-4359
Mailing Address - Country:US
Mailing Address - Phone:917-561-5263
Mailing Address - Fax:214-935-5052
Practice Address - Street 1:5600 W LOVERS LN STE 100
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75209-4359
Practice Address - Country:US
Practice Address - Phone:214-729-6299
Practice Address - Fax:214-935-5052
Is Sole Proprietor?:No
Enumeration Date:2008-07-02
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY42442207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200945770Medicaid
KY3726869000OtherPASSPORT ADVANTAGE SPECIALITY
KY50024903OtherPASSPORT PCP
KY7100074260Medicaid
KY9841363OtherAETNA
KY000000610798OtherANTHEM
KY3726873000OtherPASSPORT ADVANTAGE PCP
KY000000610799OtherANTHEM
KY3726877000OtherPASSPORT ADVANTAGE
KY50024899OtherPASSPORT SPECIALITY
KY50024907OtherPASSPORT SPECIALITY
KY3726873000OtherPASSPORT ADVANTAGE PCP
KY7100074260Medicaid