Basic Information
| Provider Information | |||||||||
| NPI: | 1528276128 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHEPHERD | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 717 STATE STREET, SUITE 16 LL | ||||||||
| Address2: | REGIONAL HEALTH SERVICES, INC | ||||||||
| City: | ERIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 165011360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8148777100 | ||||||||
| FaxNumber: | 8148772939 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 CRESCENT PARK WEST | ||||||||
| Address2: | WARREN EMERGENCY ROOM | ||||||||
| City: | WARREN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 163652111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8147232510 | ||||||||
| FaxNumber: | 8147234654 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2007 | ||||||||
| LastUpdateDate: | 06/23/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | OS012810 | PA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1009109580001 | 05 | PA | MEDICAID | BS8504195 | 01 | FEDERAL DEA | OTHER |