Provider Demographics
NPI:1063672251
Name:SHEPPARD, JACQUELINE M
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:M
Last Name:SHEPPARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 DARROW PL
Mailing Address - Street 2:6 A
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10475-1802
Mailing Address - Country:US
Mailing Address - Phone:718-974-2819
Mailing Address - Fax:
Practice Address - Street 1:140 DARROW PL
Practice Address - Street 2:6 A
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10475-1802
Practice Address - Country:US
Practice Address - Phone:718-974-2819
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-11
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY293191-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse