Healthcare Provider Details

I. General information

NPI: 1396442604
Provider Name (Legal Business Name): JACK P SHELLEY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2023
Last Update Date: 08/18/2023
Certification Date: 08/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 ELSINORE PL STE 500
CINCINNATI OH
45202-1455
US

IV. Provider business mailing address

1110 E MAIN ST APT 210
LEBANON OH
45036-6444
US

V. Phone/Fax

Practice location:
  • Phone: 513-231-6630
  • Fax:
Mailing address:
  • Phone: 513-883-8817
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS.2309726
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: