Provider Demographics
NPI:1386499184
Name:SPROUSE, JESSE RYAN
Entity type:Individual
Prefix:MR
First Name:JESSE
Middle Name:RYAN
Last Name:SPROUSE
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 1:1324 WILLOWDALE AVE
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-5148
Mailing Address - Country:US
Mailing Address - Phone:937-361-9391
Mailing Address - Fax:937-918-7161
Practice Address - Street 1:1324 WILLOWDALE AVE
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-5148
Practice Address - Country:US
Practice Address - Phone:937-361-9391
Practice Address - Fax:937-918-7161
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-23
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)