Jeff William Shively, LICSW

Primary specialty

Clinical Social WorkerTaxonomy code 1041C0700X

License

18053 Issued in MN

Practice address

12805 Highway 55
Suite 200
Plymouth, MN 55441-3859

Phone

(612) 723-0408

Fax

(763) 210-5379

NPI assigned

Feb 5, 2009

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in MN

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: No
• Power mobility devices: No
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Soul Work Counseling, LLC

  • Community/Behavioral Health Agency
  • Blaine, MN
  • NPI 1710295001
  Medicare reassignment NPD
• Relate Inc

  dba Relate

  • Community/Behavioral Health Agency
  • Minnetonka, MN
  • NPI 1053486902
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1233792000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1362441600000",
    "number": "1376782961",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "12805 HIGHWAY 55",
            "address_2": "SUITE 200",
            "city": "PLYMOUTH",
            "state": "MN",
            "postal_code": "554413859",
            "telephone_number": "612-723-0408",
            "fax_number": "763-210-5379"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "12805 HIGHWAY 55",
            "address_2": "SUITE 200",
            "city": "PLYMOUTH",
            "state": "MN",
            "postal_code": "554413859",
            "telephone_number": "612-723-0408",
            "fax_number": "763-210-5379"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "SHIVELY",
        "first_name": "JEFF",
        "middle_name": "WILLIAM",
        "credential": "LICSW",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2009-02-05",
        "last_updated": "2013-03-05",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "MN",
            "license": "18053",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Shepherd Wellness, LLC
• Jennifer Lynn Shepherd, MSW, L.I.C.S.W.
• Summer L Shepstone, OTR/L
• Brittany Shervey
• Michael Bradley Shinder, DC
• Kari Shoemaker, M.S
• Emily Mae Shopek, LICSW
• Jeff Shorten, PHARMD
• SHP V WSLG Plymouth LLC (The Waters of Plymouth)
• SHS-MN, Inc (Seniors Helping Seniors)

• Clinical Social Worker in Plymouth, MN
• Providers in Plymouth, MN by specialty
• Clinical Social Worker in Minnesota

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 5, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.