Individual
JACQUES L SHELTON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
CRNA
Contact information
Practice address
234 GOODMAN ST, ANESTHESIA INTENSIVE CARE CONSULTANTS INC, CINCINNATI, OH 45219-2364
(513) 558-4194
(513) 558-0995
Mailing address
PO BOX 636256, CENTRAL CREDENTIALING, CINCINNATI, OH 45263-6256
(513) 585-5502
(513) 585-5511
Taxonomy
Speciality
Code
Description
License number
State
163W00000X
Registered Nurse
RN.166462-COA1
OH
367500000X
Certified Registered Nurse Anesthetist
Primary
COA.00847-NA
OH
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000277560
ANTHEM BLUE SHIELD
—
05
—
0738778
—
OH
05
—
100388250
—
IN
01
—
617610
WELLCARE
KY
01
—
728035
BUCKEYE
—
05
—
74369539
—
KY
Enumeration date
12/08/2005
Last updated
06/05/2017
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