Provider Demographics
NPI:1497253017
Name:JESSUP, ASHLEY DANIELLA
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:DANIELLA
Last Name:JESSUP
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 NW 13TH CT
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33311-5943
Mailing Address - Country:US
Mailing Address - Phone:786-759-8373
Mailing Address - Fax:
Practice Address - Street 1:10537 SW 13TH CT
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33025-4766
Practice Address - Country:US
Practice Address - Phone:754-200-3417
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-29
Last Update Date:2018-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician