Provider Demographics
NPI:1407932296
Name:LEAGUE, JONATHAN MICHAEL (LPCC, LCDC)
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:MICHAEL
Last Name:LEAGUE
Suffix:
Gender:M
Credentials:LPCC, LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6400 THORNBERRY COURT
Mailing Address - Street 2:UNITE 620
Mailing Address - City:MASON
Mailing Address - State:OH
Mailing Address - Zip Code:45040
Mailing Address - Country:US
Mailing Address - Phone:513-229-8386
Mailing Address - Fax:513-229-8385
Practice Address - Street 1:6400 THORNBERRY COURT
Practice Address - Street 2:UNITE 620
Practice Address - City:MASON
Practice Address - State:OH
Practice Address - Zip Code:45040
Practice Address - Country:US
Practice Address - Phone:513-229-8386
Practice Address - Fax:513-229-8385
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2009-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH021055101YA0400X
OHE 4364101YP2500X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000477472OtherBCBS/ANTHEM ID