Provider Demographics
NPI:1235273426
Name:SHELTON, JEREMIAH M (PT)
Entity Type:Individual
Prefix:MR
First Name:JEREMIAH
Middle Name:M
Last Name:SHELTON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11009
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98508-1009
Mailing Address - Country:US
Mailing Address - Phone:360-352-2037
Mailing Address - Fax:
Practice Address - Street 1:3333 HARRISON AVE NW
Practice Address - Street 2:SUITE 102
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-5049
Practice Address - Country:US
Practice Address - Phone:360-292-7245
Practice Address - Fax:360-292-7247
Is Sole Proprietor?:No
Enumeration Date:2007-02-19
Last Update Date:2008-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00009155225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0218612OtherL & I
WA8346358Medicaid
WA3333SH / 1175SHOtherREGENCE
WAG8866459Medicare PIN