Provider Demographics
NPI:1902287683
Name:SHEPPARD, JACOB (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:
Last Name:SHEPPARD
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2105 ACADEMY RD STE J
Mailing Address - Street 2:
Mailing Address - City:POWHATAN
Mailing Address - State:VA
Mailing Address - Zip Code:23139-5829
Mailing Address - Country:US
Mailing Address - Phone:804-598-8951
Mailing Address - Fax:804-598-7527
Practice Address - Street 1:210 N 4TH AVE
Practice Address - Street 2:
Practice Address - City:HOPEWELL
Practice Address - State:VA
Practice Address - Zip Code:23860-2504
Practice Address - Country:US
Practice Address - Phone:804-458-3004
Practice Address - Fax:804-458-3056
Is Sole Proprietor?:No
Enumeration Date:2015-06-17
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014148981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice