Provider Demographics
NPI:1518300144
Name:JESSUP, JOHN PAGE (PSYCHOLOGIST, MA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:PAGE
Last Name:JESSUP
Suffix:
Gender:M
Credentials:PSYCHOLOGIST, MA
Other - Prefix:
Other - First Name:JACK
Other - Middle Name:
Other - Last Name:JESSUP
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA, LP
Mailing Address - Street 1:1085 US-4 EAST
Mailing Address - Street 2:SUITE 2A
Mailing Address - City:RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05701
Mailing Address - Country:US
Mailing Address - Phone:802-417-2067
Mailing Address - Fax:
Practice Address - Street 1:1085 US ROUTE 4 E STE 2A
Practice Address - Street 2:
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-8007
Practice Address - Country:US
Practice Address - Phone:802-417-2067
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-13
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT047.0123038103TC2200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent