Provider Demographics
NPI:1942552245
Name:JESSUP, BRYN W (PHD)
Entity Type:Individual
Prefix:DR
First Name:BRYN
Middle Name:W
Last Name:JESSUP
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:778 W FRONTAGE RD
Mailing Address - Street 2:114
Mailing Address - City:NORTHFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60093-1209
Mailing Address - Country:US
Mailing Address - Phone:847-501-5897
Mailing Address - Fax:847-501-5896
Practice Address - Street 1:778 W FRONTAGE RD
Practice Address - Street 2:114
Practice Address - City:NORTHFIELD
Practice Address - State:IL
Practice Address - Zip Code:60093-1209
Practice Address - Country:US
Practice Address - Phone:847-501-5897
Practice Address - Fax:847-501-5896
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-10
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071003787103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical