Provider Demographics
NPI:1518927789
Name:JESSUP, DAVID MILLER (MS, ATC)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:MILLER
Last Name:JESSUP
Suffix:
Gender:M
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 LACY CT
Mailing Address - Street 2:
Mailing Address - City:BROWNSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:46112-2033
Mailing Address - Country:US
Mailing Address - Phone:317-852-9651
Mailing Address - Fax:
Practice Address - Street 1:1000 S ODELL ST
Practice Address - Street 2:
Practice Address - City:BROWNSBURG
Practice Address - State:IN
Practice Address - Zip Code:46112-1929
Practice Address - Country:US
Practice Address - Phone:317-852-2258
Practice Address - Fax:317-852-1495
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36000085A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer