Healthcare Provider Details

I. General information

NPI: 1134944788
Provider Name (Legal Business Name): JEREMY DOUGLAS SHEPHERD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/19/2024
Last Update Date: 01/10/2025
Certification Date: 01/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

651 DUNLOP LN
CLARKSVILLE TN
37040-5015
US

IV. Provider business mailing address

651 DUNLOP LN
CLARKSVILLE TN
37040-5015
US

V. Phone/Fax

Practice location:
  • Phone: 931-502-1000
  • Fax:
Mailing address:
  • Phone: 931-502-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code146L00000X
TaxonomyParamedic
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number259150
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number37981
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: