Provider Demographics
NPI:1811551591
Name:JESSOP, MELISSA DAWN (DPT)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:DAWN
Last Name:JESSOP
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2998 E HARVEST LN
Mailing Address - Street 2:
Mailing Address - City:EAGLE MOUNTAIN
Mailing Address - State:UT
Mailing Address - Zip Code:84005-4569
Mailing Address - Country:US
Mailing Address - Phone:406-381-4608
Mailing Address - Fax:
Practice Address - Street 1:2870 JUNIPER DR
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-4720
Practice Address - Country:US
Practice Address - Phone:208-746-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-27
Last Update Date:2019-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018040833225100000X
MTPTP-PT-LIC-13205225100000X
UT10943330-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist