Healthcare Provider Details

I. General information

NPI: 1972381473
Provider Name (Legal Business Name): JAELYNN ALEXANDRA SHOUP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2023
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 E BOALT ST STE E
SANDUSKY OH
44870-4144
US

IV. Provider business mailing address

13615 RILEY RD
MILAN OH
44846-9466
US

V. Phone/Fax

Practice location:
  • Phone: 734-600-7873
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberS.2309873
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: