Healthcare Provider Details

I. General information

NPI: 1538735626
Provider Name (Legal Business Name): JADE MICHELLE SHELTON LIAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2021
Last Update Date: 10/14/2025
Certification Date: 10/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 N CENTRAL AVE FL 18
PHOENIX AZ
85004-2322
US

IV. Provider business mailing address

2 N CENTRAL AVE FL 18
PHOENIX AZ
85004-2322
US

V. Phone/Fax

Practice location:
  • Phone: 646-941-7645
  • Fax:
Mailing address:
  • Phone: 646-941-7645
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number155390
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: