Provider Demographics
NPI:1952353781
Name:SHEPHERD, JACK P (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:P
Last Name:SHEPHERD
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:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:330 BILLINGSLEY RD STE 101
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-5020
Practice Address - Country:US
Practice Address - Phone:704-316-2333
Practice Address - Fax:704-316-2334
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200201174207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCN01174Medicaid
NC89132W1Medicaid
NCG77352Medicare UPIN
NC2010874Medicare ID - Type Unspecified
NC89132W1Medicaid