Healthcare Provider Details

I. General information

NPI: 1992221154
Provider Name (Legal Business Name): JERMAINE SHEPPARD PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2017
Last Update Date: 07/14/2022
Certification Date: 07/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15204 W COLONIAL DR
WINTER GARDEN FL
34787-6042
US

IV. Provider business mailing address

881 BENDING OAK TRL
WINTER GARDEN FL
34787-2457
US

V. Phone/Fax

Practice location:
  • Phone: 407-373-9610
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA27612
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: