Healthcare Provider Details

I. General information

NPI: 1295388452
Provider Name (Legal Business Name): JACQUELYN SUE ALLISON PEER SUPPORT SPECIAL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2019
Last Update Date: 10/28/2025
Certification Date: 10/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 E WOODBURY DR STE 110
DAYTON OH
45415-2853
US

IV. Provider business mailing address

77 E WOODBURY DR STE 110
DAYTON OH
45415-2853
US

V. Phone/Fax

Practice location:
  • Phone: 937-972-8455
  • Fax:
Mailing address:
  • Phone: 937-789-2519
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.185310
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberCDCA.185310
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number1355
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: