Provider Demographics
NPI:1730574963
Name:SHEPHERD, JACOB MATTHEW (MD)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:MATTHEW
Last Name:SHEPHERD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 E 104TH ST
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64131-4517
Mailing Address - Country:US
Mailing Address - Phone:214-984-2351
Mailing Address - Fax:
Practice Address - Street 1:331 SIJEN AVE
Practice Address - Street 2:
Practice Address - City:WHITEMAN AFB
Practice Address - State:MO
Practice Address - Zip Code:65305
Practice Address - Country:US
Practice Address - Phone:660-287-2180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-03
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAMD-44454171000000X
MO2018023747208M00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No171000000XOther Service ProvidersMilitary Health Care ProviderGroup - Single Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Single Specialty