Provider Demographics
NPI:1649831207
Name:HENIZE, JESSICA LEA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LEA
Last Name:HENIZE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:LEA
Other - Last Name:CLARKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8153 TOLLBRIDGE CT
Mailing Address - Street 2:
Mailing Address - City:WEST CHESTER
Mailing Address - State:OH
Mailing Address - Zip Code:45069-1692
Mailing Address - Country:US
Mailing Address - Phone:513-413-4458
Mailing Address - Fax:
Practice Address - Street 1:1215 1ST AVE
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:OH
Practice Address - Zip Code:45044-4117
Practice Address - Country:US
Practice Address - Phone:513-849-2081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-25
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.168660101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)