Provider Demographics
NPI:1205674389
Name:SHETLAR, JACKSON CADE (OD)
Entity type:Individual
Prefix:
First Name:JACKSON
Middle Name:CADE
Last Name:SHETLAR
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 E IRON AVE
Mailing Address - Street 2:
Mailing Address - City:SALINA
Mailing Address - State:KS
Mailing Address - Zip Code:67401-3237
Mailing Address - Country:US
Mailing Address - Phone:785-825-4679
Mailing Address - Fax:785-825-5898
Practice Address - Street 1:1601 E IRON AVE
Practice Address - Street 2:
Practice Address - City:SALINA
Practice Address - State:KS
Practice Address - Zip Code:67401-3237
Practice Address - Country:US
Practice Address - Phone:785-825-4679
Practice Address - Fax:785-825-5898
Is Sole Proprietor?:No
Enumeration Date:2024-07-15
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2231152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist