Healthcare Provider Details

I. General information

NPI: 1740148212
Provider Name (Legal Business Name): JONATHAN RANDALL KELLY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/13/2026
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1526 WITTLOU AVE
CINCINNATI OH
45224-2155
US

IV. Provider business mailing address

1526 WITTLOU AVE
CINCINNATI OH
45224-2155
US

V. Phone/Fax

Practice location:
  • Phone: 513-808-2229
  • Fax:
Mailing address:
  • Phone: 513-808-2229
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number196082
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberAPS.007350
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: