Provider Demographics
NPI:1043414857
Name:SHELTON, JIMMIE JO (OTA)
Entity Type:Individual
Prefix:
First Name:JIMMIE
Middle Name:JO
Last Name:SHELTON
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1513 BOWIE DR
Mailing Address - Street 2:
Mailing Address - City:CORSICANA
Mailing Address - State:TX
Mailing Address - Zip Code:75110-2815
Mailing Address - Country:US
Mailing Address - Phone:903-673-1537
Mailing Address - Fax:
Practice Address - Street 1:3002 W 2ND AVE
Practice Address - Street 2:
Practice Address - City:CORSICANA
Practice Address - State:TX
Practice Address - Zip Code:75110-2408
Practice Address - Country:US
Practice Address - Phone:903-641-0545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX209455224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant