MEDICARE: JONATHAN RANDALL KELLY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	175T00000X	Peer Specialist	APS.007350	OH
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	196082	OH

General Provider Information

NPI Number	:	1740148212
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JONATHAN RANDALL KELLY

Provider Business Mailing Address
First Line	:	1526 WITTLOU AVE
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45224-2155
Country	:	US
Telephone Number	:	513-808-2229
Fax Number	:

Provider Business Practice Location Address
First Line	:	1526 WITTLOU AVE
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45224-2155
Country	:	US
Telephone Number	:	513-808-2229
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/13/2026
Last Update Date	:	05/14/2026

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