Provider Demographics
NPI:1124592977
Name:JESSUP, DILDRA (LPCA)
Entity Type:Individual
Prefix:
First Name:DILDRA
Middle Name:
Last Name:JESSUP
Suffix:
Gender:F
Credentials:LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 63
Mailing Address - Street 2:
Mailing Address - City:BLADENBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28320-0063
Mailing Address - Country:US
Mailing Address - Phone:910-874-0647
Mailing Address - Fax:
Practice Address - Street 1:2940 BREEZEWOOD AVE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303-5520
Practice Address - Country:US
Practice Address - Phone:910-817-2650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-15
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA14413101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional