Provider Demographics
NPI:1942806914
Name:SHELTON, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:SHELTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1204 STUBBS AVE STE B
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-5631
Mailing Address - Country:US
Mailing Address - Phone:318-582-5633
Mailing Address - Fax:
Practice Address - Street 1:908 SILO AVE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:OK
Practice Address - Zip Code:73448-7308
Practice Address - Country:US
Practice Address - Phone:209-324-3863
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-07
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA171M00000XMedicaid