Healthcare Provider Details

I. General information

NPI: 1720434145
Provider Name (Legal Business Name): JESSE SANDERS PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2016
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1561 OLD LEONARD AVE
COLUMBUS OH
43219-2580
US

IV. Provider business mailing address

6432 E MAIN ST STE 101
REYNOLDSBURG OH
43068-2368
US

V. Phone/Fax

Practice location:
  • Phone: 614-655-4300
  • Fax: 614-695-5300
Mailing address:
  • Phone: 614-655-4300
  • Fax: 614-695-5300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number463081342
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberC2002994387
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License NumberC2002994387
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: