Provider Demographics
NPI:1972020790
Name:LEU, JESSIE ALLAN
Entity Type:Individual
Prefix:
First Name:JESSIE
Middle Name:ALLAN
Last Name:LEU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:268 KARSON DR
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44312-3670
Mailing Address - Country:US
Mailing Address - Phone:330-554-0906
Mailing Address - Fax:
Practice Address - Street 1:885 E BUCHTEL AVE
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44305-2338
Practice Address - Country:US
Practice Address - Phone:330-996-2222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-23
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH163042101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH163042Medicaid