Provider Demographics
NPI:1851578637
Name:JESSUP, DAMON KEITH (CRNA)
Entity Type:Individual
Prefix:
First Name:DAMON
Middle Name:KEITH
Last Name:JESSUP
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1303
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30475-1303
Mailing Address - Country:US
Mailing Address - Phone:912-538-5537
Mailing Address - Fax:912-538-5228
Practice Address - Street 1:1 MEADOWS PKWY
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-8759
Practice Address - Country:US
Practice Address - Phone:912-538-5537
Practice Address - Fax:912-538-5228
Is Sole Proprietor?:No
Enumeration Date:2008-01-24
Last Update Date:2015-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN131653367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA462913918BMedicaid
GA462913918AMedicaid
GA462913918CMedicaid
GA462913918BMedicaid
GA462913918CMedicaid