MEDICARE: MRS. JACQUELINE CRADY SHEPARD CNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	372500000X	Chore Provider	CNA254629	FL
2	372600000X	Adult Companion	CNA254629	FL
3	374U00000X	Home Health Aide	CNA254629	FL
4	376K00000X	Nurse's Aide	CNA254629	FL
5	3747P1801X	Personal Care Attendant	CNA254629	FL

General Provider Information

NPI Number	:	1881187672
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JACQUELINE CRADY SHEPARD CNA

Provider Business Mailing Address
First Line	:	85147 CRADY LAKE DR
Second Line	:
City	:	YULEE
State	:	FL
Zip	:	32097-6849
Country	:	US
Telephone Number	:	904-646-7576
Fax Number	:

Provider Business Practice Location Address
First Line	:	85147 CRADY LAKE DR
Second Line	:
City	:	YULEE
State	:	FL
Zip	:	32097-6849
Country	:	US
Telephone Number	:	904-646-7576
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/07/2018
Last Update Date	:	06/07/2018

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