Provider Demographics
NPI:1922586379
Name:HENRY, JONATHON ELEEOT (LSW)
Entity Type:Individual
Prefix:
First Name:JONATHON
Middle Name:ELEEOT
Last Name:HENRY
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 1:1869 SHELDON AVE
Mailing Address - Street 2:
Mailing Address - City:EAST CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44112-2826
Mailing Address - Country:US
Mailing Address - Phone:216-703-5334
Mailing Address - Fax:
Practice Address - Street 1:36000 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094
Practice Address - Country:US
Practice Address - Phone:440-375-8934
Practice Address - Fax:440-602-6583
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-29
Last Update Date:2018-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1501145104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0066766Medicaid