Provider Demographics
NPI:1649754318
Name:JESSUP, SUZANNE
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:
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 1:555 NORTHGATE DR
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-3680
Mailing Address - Country:US
Mailing Address - Phone:415-526-7500
Mailing Address - Fax:
Practice Address - Street 1:1682 NOVATO BLVD
Practice Address - Street 2:
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94947-7000
Practice Address - Country:US
Practice Address - Phone:415-473-2721
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-19
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMPSS-FWQXYL175T00000X
CA101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No175T00000XOther Service ProvidersPeer Specialist