Provider Demographics
NPI:1457537862
Name:SHELTON, JARED MARK (DC, BS, CSCS)
Entity Type:Individual
Prefix:DR
First Name:JARED
Middle Name:MARK
Last Name:SHELTON
Suffix:
Gender:M
Credentials:DC, BS, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 W CENTER ST
Mailing Address - Street 2:
Mailing Address - City:SODA SPRINGS
Mailing Address - State:ID
Mailing Address - Zip Code:83276-1530
Mailing Address - Country:US
Mailing Address - Phone:208-547-4518
Mailing Address - Fax:208-547-4555
Practice Address - Street 1:45 W CENTER ST
Practice Address - Street 2:
Practice Address - City:SODA SPRINGS
Practice Address - State:ID
Practice Address - Zip Code:83276-1530
Practice Address - Country:US
Practice Address - Phone:208-547-4518
Practice Address - Fax:208-547-4555
Is Sole Proprietor?:No
Enumeration Date:2008-01-16
Last Update Date:2008-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-1284111N00000X, 111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
No111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807952000Medicaid
ID1673568OtherMEDICARE INDIVIDUAL PTAN