Provider Demographics
NPI:1467437772
Name:SHELTON, JACQUES L (CRNA)
Entity Type:Individual
Prefix:
First Name:JACQUES
Middle Name:L
Last Name:SHELTON
Suffix:
Gender:M
Credentials:CRNA
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 636256
Mailing Address - Street 2:CENTRAL CREDENTIALING
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6256
Mailing Address - Country:US
Mailing Address - Phone:513-585-5502
Mailing Address - Fax:513-585-5511
Practice Address - Street 1:234 GOODMAN ST
Practice Address - Street 2:ANESTHESIA INTENSIVE CARE CONSULTANTS INC
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219-2364
Practice Address - Country:US
Practice Address - Phone:513-558-4194
Practice Address - Fax:513-558-0995
Is Sole Proprietor?:No
Enumeration Date:2005-12-08
Last Update Date:2017-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.166462-COA1163W00000X
OHCOA.00847-NA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY617610OtherWELLCARE
KY74369539Medicaid
000000277560OtherANTHEM BLUE SHIELD
OH0738778Medicaid
IN100388250Medicaid
728035OtherBUCKEYE
KY74369539Medicaid
OHSH8200497Medicare ID - Type Unspecified