Provider Demographics
NPI:1043761059
Name:SHELLER, JASON
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:SHELLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3920 LOVERS LN
Mailing Address - Street 2:
Mailing Address - City:RAVENNA
Mailing Address - State:OH
Mailing Address - Zip Code:44266-4200
Mailing Address - Country:US
Mailing Address - Phone:330-673-1347
Mailing Address - Fax:
Practice Address - Street 1:3920 LOVERS LN
Practice Address - Street 2:
Practice Address - City:RAVENNA
Practice Address - State:OH
Practice Address - Zip Code:44266-4200
Practice Address - Country:US
Practice Address - Phone:330-673-1347
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-14
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.1700263101YM0800X
OHCDCA.150199101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health