Provider Demographics
NPI:1447507306
Name:SHELTON, JESSICA M (PT, MSPT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:M
Last Name:SHELTON
Suffix:
Gender:F
Credentials:PT, MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 W SENECA ST STE 12
Mailing Address - Street 2:
Mailing Address - City:MANLIUS
Mailing Address - State:NY
Mailing Address - Zip Code:13104-2422
Mailing Address - Country:US
Mailing Address - Phone:315-682-0325
Mailing Address - Fax:315-682-0323
Practice Address - Street 1:2106 EXECUTIVE DR
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-2402
Practice Address - Country:US
Practice Address - Phone:757-838-6678
Practice Address - Fax:757-838-8116
Is Sole Proprietor?:No
Enumeration Date:2012-08-10
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305207576225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC05954OtherGROUP MEDICARE PTAN
VA1447507306Medicaid
VAQ40401AMedicare PIN