Provider Demographics
NPI:1861725921
Name:SHEPARD, JON M (LP)
Entity type:Individual
Prefix:DR
First Name:JON
Middle Name:M
Last Name:SHEPARD
Suffix:
Gender:M
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2816 MUSKRAT DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244-5501
Mailing Address - Country:US
Mailing Address - Phone:817-229-5659
Mailing Address - Fax:
Practice Address - Street 1:4020 HUFFINES
Practice Address - Street 2:SUITE 120
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75010-6524
Practice Address - Country:US
Practice Address - Phone:817-229-5659
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-08
Last Update Date:2009-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX33286103T00000X
TX32747103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool