Provider Demographics
NPI:1821587973
Name:LEATHERWOOD, JONATHAN
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:LEATHERWOOD
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 1:221 SAINT MARYS LN
Mailing Address - Street 2:
Mailing Address - City:WAVERLY
Mailing Address - State:OH
Mailing Address - Zip Code:45690-1052
Mailing Address - Country:US
Mailing Address - Phone:740-222-2522
Mailing Address - Fax:
Practice Address - Street 1:14572 US HIGHWAY 23 STE E
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:OH
Practice Address - Zip Code:45690-9448
Practice Address - Country:US
Practice Address - Phone:740-835-6363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-04
Last Update Date:2018-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)