Provider Demographics
NPI:1508890146
Name:JESSUP, DANA DAYLE (LSCSW)
Entity Type:Individual
Prefix:
First Name:DANA
Middle Name:DAYLE
Last Name:JESSUP
Suffix:
Gender:F
Credentials:LSCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17821 78TH ST
Mailing Address - Street 2:
Mailing Address - City:MC LOUTH
Mailing Address - State:KS
Mailing Address - Zip Code:66054-5091
Mailing Address - Country:US
Mailing Address - Phone:785-742-7113
Mailing Address - Fax:785-742-3085
Practice Address - Street 1:17821 78TH ST
Practice Address - Street 2:
Practice Address - City:MC LOUTH
Practice Address - State:KS
Practice Address - Zip Code:66054-5091
Practice Address - Country:US
Practice Address - Phone:785-742-7113
Practice Address - Fax:785-742-3085
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS101YM0800X
KS31421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100097950BMedicaid
KS100097950AMedicaid