Provider Demographics
NPI:1699164285
Name:JORDAN, SHALETRA
Entity type:Individual
Prefix:
First Name:SHALETRA
Middle Name:
Last Name:JORDAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHALETRA
Other - Middle Name:
Other - Last Name:HODGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:412 OVERLAND ST
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:TX
Mailing Address - Zip Code:75633-1820
Mailing Address - Country:US
Mailing Address - Phone:903-742-0197
Mailing Address - Fax:
Practice Address - Street 1:412 OVERLAND ST
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:TX
Practice Address - Zip Code:75633-1820
Practice Address - Country:US
Practice Address - Phone:903-742-0197
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-20
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP127172367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered