Provider Demographics
NPI:1518456300
Name:SCHELLER, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:SCHELLER
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 1:1351 TURNER AVE NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49504-3235
Mailing Address - Country:US
Mailing Address - Phone:616-856-9249
Mailing Address - Fax:
Practice Address - Street 1:1260 EKHART ST NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-1380
Practice Address - Country:US
Practice Address - Phone:616-965-3492
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-07
Last Update Date:2018-05-23
Deactivation Date:2018-05-07
Deactivation Code:
Reactivation Date:2018-05-23
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician