Provider Demographics
NPI:1417342601
Name:SHEPARD, JENNIFER KAYE (MD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:KAYE
Last Name:SHEPARD
Suffix:
Gender:F
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:SELENE MEDICAL CLINIC
Mailing Address - Street 2:2829 GREAT NORTHERN LOOP SUITE 101F
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59808
Mailing Address - Country:US
Mailing Address - Phone:817-404-7481
Mailing Address - Fax:
Practice Address - Street 1:2829 GREAT NORTHERN LOOP STE 101F
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59808-1752
Practice Address - Country:US
Practice Address - Phone:406-400-9826
Practice Address - Fax:406-201-3250
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-03
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
UT10104230-1205207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT10104230-8905OtherCS LICENSE NUMBER
UT10104230-1205OtherLICENSE NUMBER