Provider Demographics
NPI:1326663766
Name:SAKURA BEHAVIORAL HEALTH LLC
Entity Type:Organization
Organization Name:SAKURA BEHAVIORAL HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER/CLINICAL COUNSELOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:SPEELMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MED, LPCC
Authorized Official - Phone:859-354-9360
Mailing Address - Street 1:125 QUINN DR
Mailing Address - Street 2:
Mailing Address - City:NICHOLASVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40356-1370
Mailing Address - Country:US
Mailing Address - Phone:859-241-3085
Mailing Address - Fax:877-712-3835
Practice Address - Street 1:125 QUINN DR
Practice Address - Street 2:
Practice Address - City:NICHOLASVILLE
Practice Address - State:KY
Practice Address - Zip Code:40356-1370
Practice Address - Country:US
Practice Address - Phone:859-241-3085
Practice Address - Fax:877-712-3835
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-11
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100677110Medicaid