Provider Demographics
NPI:1467806109
Name:JESSUP, EMILY (BCBA)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:JESSUP
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1642 N VOLUSIA AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32763-3850
Mailing Address - Country:US
Mailing Address - Phone:386-628-0295
Mailing Address - Fax:
Practice Address - Street 1:1642 N VOLUSIA AVE STE 201
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-3850
Practice Address - Country:US
Practice Address - Phone:386-628-0295
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019777800Medicaid