Provider Demographics
NPI:1669175865
Name:JESSUP, TINA RAE (LCSW)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:RAE
Last Name:JESSUP
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7425 N MONA LISA RD APT 131
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85741-4506
Mailing Address - Country:US
Mailing Address - Phone:505-289-6540
Mailing Address - Fax:
Practice Address - Street 1:39580 S LAGO DEL ORO PKWY
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85739-1091
Practice Address - Country:US
Practice Address - Phone:844-335-1495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-24
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA297571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical