Provider Demographics
NPI:1295388452
Name:ALLISON, JACQUELYN SUE (PEER SUPPORT SPECIAL)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:SUE
Last Name:ALLISON
Suffix:
Gender:F
Credentials:PEER SUPPORT SPECIAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 E WOODBURY DR STE 110
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45415-2853
Mailing Address - Country:US
Mailing Address - Phone:937-789-2519
Mailing Address - Fax:
Practice Address - Street 1:77 E WOODBURY DR STE 110
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45415-2853
Practice Address - Country:US
Practice Address - Phone:937-972-8455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-17
Last Update Date:2025-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1355175T00000X
OHCDCA.185310171M00000X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer Specialist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator