Provider Demographics
NPI:1972020790
Name:LEU, JESSIE ALLAN
Entity type:Individual
Prefix:
First Name:JESSIE
Middle Name:ALLAN
Last Name:LEU
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 1:3500 LORAIN AVE STE 407
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44113-3726
Mailing Address - Country:US
Mailing Address - Phone:216-250-1607
Mailing Address - Fax:216-304-6669
Practice Address - Street 1:3500 LORAIN AVE STE 407
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44113-3726
Practice Address - Country:US
Practice Address - Phone:216-250-1607
Practice Address - Fax:216-304-6669
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-23
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.2303972101YM0800X
OH163042101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH163042Medicaid