Provider Demographics
NPI:1588237770
Name:SULLIVAN, JESSIE E
Entity Type:Individual
Prefix:
First Name:JESSIE
Middle Name:E
Last Name:SULLIVAN
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 1:130 S SPRINGVIEW DR
Mailing Address - Street 2:
Mailing Address - City:ENTERPRISE
Mailing Address - State:AL
Mailing Address - Zip Code:36330-5060
Mailing Address - Country:US
Mailing Address - Phone:151-752-8055
Mailing Address - Fax:
Practice Address - Street 1:2543 ROSS CLARK CIR STE 5
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-4916
Practice Address - Country:US
Practice Address - Phone:334-699-4007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-23
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty