Provider Demographics
NPI:1003328865
Name:JESSUP, KEVIN (LAC)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:JESSUP
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4214 N 19TH PL
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-5427
Mailing Address - Country:US
Mailing Address - Phone:602-460-5350
Mailing Address - Fax:
Practice Address - Street 1:4214 N 19TH PL
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-5427
Practice Address - Country:US
Practice Address - Phone:602-460-5350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-01
Last Update Date:2017-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-14006101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty