Provider Demographics
NPI:1063994192
Name:JEWELL, SHANE DAVID (LSW)
Entity type:Individual
Prefix:MR
First Name:SHANE
Middle Name:DAVID
Last Name:JEWELL
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:752 MOULL ST APT B
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-2993
Mailing Address - Country:US
Mailing Address - Phone:740-877-9068
Mailing Address - Fax:
Practice Address - Street 1:2112 CHERRY VALLEY RD
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-1323
Practice Address - Country:US
Practice Address - Phone:740-755-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-05
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1701365104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker