Provider Demographics
NPI:1942559802
Name:CHARLES E JESSUP DO PLLC
Entity Type:Organization
Organization Name:CHARLES E JESSUP DO PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:E
Authorized Official - Last Name:JESSUP
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:989-684-1120
Mailing Address - Street 1:3068 HIDDEN RD
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48706-1241
Mailing Address - Country:US
Mailing Address - Phone:989-684-1120
Mailing Address - Fax:989-391-9408
Practice Address - Street 1:4599 TOWNE CENTRE RD
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48604-2804
Practice Address - Country:US
Practice Address - Phone:989-497-3000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-06
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101005335207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty