Provider Demographics
NPI:1457396251
Name:MELANIE JESSUP, DPM, PLLC
Entity Type:Organization
Organization Name:MELANIE JESSUP, DPM, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MELANIE
Authorized Official - Middle Name:R
Authorized Official - Last Name:JESSUP
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:248-596-1548
Mailing Address - Street 1:20415 NORTHVILLE PLACE DR
Mailing Address - Street 2:#2308
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48167-2944
Mailing Address - Country:US
Mailing Address - Phone:248-596-1548
Mailing Address - Fax:248-596-1548
Practice Address - Street 1:20415 NORTHVILLE PLACE DR
Practice Address - Street 2:#2308
Practice Address - City:NORTHVILLE
Practice Address - State:MI
Practice Address - Zip Code:48167-2944
Practice Address - Country:US
Practice Address - Phone:248-596-1548
Practice Address - Fax:248-596-1548
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901002083213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4853712Medicaid
MIV06902Medicare UPIN
MI4853712Medicaid