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General NPI Number Information
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NPI Number | 1265132211
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Entity Type | Individual
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Provider Name | JACOB MICHAEL SHELLEY CDCA/CPRS
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Gender | Male
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Dates
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Enumeration Date | 03/08/2023
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Last Update Date | 10/30/2025
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Provider Practice Location Address
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Address Line | 343 TROY ST
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City | DAYTON
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State | OH
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Zip | 45404-1830
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Country | US
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Telephone | 937-949-1524
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Fax |
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Provider Business Mailing Address
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Address Line | 343 TROY ST
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City | DAYTON
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State | OH
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Zip | 45404-1830
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 175T00000X
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Taxonomy Name | Peer Specialist
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License Number | APS.003608
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License Number State | OH
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Taxonomy #2
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | CDCA.187249
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License Number State | OH
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