Provider Demographics
NPI:1134187156
Name:JEWELL, SHANNON ARLEESE (MD)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:ARLEESE
Last Name:JEWELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3101 SE 14TH ST
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-4900
Mailing Address - Country:US
Mailing Address - Phone:479-636-9234
Mailing Address - Fax:479-636-0774
Practice Address - Street 1:3101 SE 14TH ST
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-4900
Practice Address - Country:US
Practice Address - Phone:479-636-9234
Practice Address - Fax:479-636-0774
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2011-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE08392080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR131827001Medicaid
AR131827001Medicaid
AR5K516Medicare PIN