Provider Demographics
NPI:1134596125
Name:SHEPHERD, JESSICA MARIE (AGCNS-BC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:SHEPHERD
Suffix:
Gender:F
Credentials:AGCNS-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5061 W WAVERLY RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72704-6957
Mailing Address - Country:US
Mailing Address - Phone:479-790-2805
Mailing Address - Fax:
Practice Address - Street 1:3900 N PARKVIEW DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-6398
Practice Address - Country:US
Practice Address - Phone:479-966-4187
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-26
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARS002300364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist