Healthcare Provider Details

I. General information

NPI: 1811867153
Provider Name (Legal Business Name): JACK CHRISTIAN SHEPHARD RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2025
Last Update Date: 11/11/2025
Certification Date: 11/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4831 35TH AVE SW
SEATTLE WA
98126-2709
US

IV. Provider business mailing address

4831 35TH AVE SW
SEATTLE WA
98126-2709
US

V. Phone/Fax

Practice location:
  • Phone: 206-923-3941
  • Fax: 206-923-3941
Mailing address:
  • Phone: 206-923-3941
  • Fax: 206-923-3941

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License NumberRN60389134
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: