Provider Demographics
NPI:1144408618
Name:JESSUP, STEVEN I (MA LIC ATC)
Entity Type:Individual
Prefix:MR
First Name:STEVEN
Middle Name:I
Last Name:JESSUP
Suffix:
Gender:M
Credentials:MA LIC ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:980 IRONWOOD DR.
Mailing Address - Street 2:SUITE 207
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814
Mailing Address - Country:US
Mailing Address - Phone:208-770-2971
Mailing Address - Fax:
Practice Address - Street 1:980 W IRONWOOD DR
Practice Address - Street 2:SUITE 207
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2668
Practice Address - Country:US
Practice Address - Phone:208-770-2971
Practice Address - Fax:208-770-2974
Is Sole Proprietor?:No
Enumeration Date:2008-02-06
Last Update Date:2014-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDAT-2602255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer