Basic Information
| Provider Information | |||||||||
| NPI: | 1598112054 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHEPHERD | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | NATHANIEL | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3360 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972083360 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1620 COOPER POINT RD SW STE 200 | ||||||||
| Address2: | |||||||||
| City: | OLYMPIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985025736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604866710 | ||||||||
| FaxNumber: | 3607050614 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2016 | ||||||||
| LastUpdateDate: | 10/08/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA60807187 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.