Provider Demographics
NPI:1912033804
Name:PIERCE, JESSUP DANIEL (ATC)
Entity Type:Individual
Prefix:MR
First Name:JESSUP
Middle Name:DANIEL
Last Name:PIERCE
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 WASHINGTON AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:SCHENECTADY
Mailing Address - State:NY
Mailing Address - Zip Code:12305-1792
Mailing Address - Country:US
Mailing Address - Phone:518-429-0306
Mailing Address - Fax:
Practice Address - Street 1:432 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12203-1419
Practice Address - Country:US
Practice Address - Phone:518-454-5134
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0014532255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer