Healthcare Provider Details

I. General information

NPI: 1720064223
Provider Name (Legal Business Name): JENNIFER SHEPHERD APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2005
Last Update Date: 04/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 WEST COURT STREET.
JASPER AR
72641
US

IV. Provider business mailing address

103 BOGY AVE
HARRISON AR
72601-6706
US

V. Phone/Fax

Practice location:
  • Phone: 870-446-2203
  • Fax: 870-446-2206
Mailing address:
  • Phone: 870-743-9365
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA01229
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: