Provider Demographics
NPI:1205819166
Name:JESSUP, JOHN G (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:G
Last Name:JESSUP
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 HIGHWAY 78 E
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:AL
Mailing Address - Zip Code:35501-8956
Mailing Address - Country:US
Mailing Address - Phone:205-387-4401
Mailing Address - Fax:
Practice Address - Street 1:1280 SUMMITT
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:AL
Practice Address - Zip Code:35501-0102
Practice Address - Country:US
Practice Address - Phone:205-387-7555
Practice Address - Fax:205-384-9006
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME53910207RP1001X
AL14603207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL113118Medicaid
AL102I296927Medicare PIN