Provider Demographics
NPI:1780084152
Name:JESSUP, IRIS RAMONA
Entity type:Individual
Prefix:
First Name:IRIS
Middle Name:RAMONA
Last Name:JESSUP
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3030 S JONES BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89146-6793
Mailing Address - Country:US
Mailing Address - Phone:702-562-1238
Mailing Address - Fax:
Practice Address - Street 1:3030 S JONES BLVD STE 110
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-6793
Practice Address - Country:US
Practice Address - Phone:702-562-1238
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-03
Last Update Date:2014-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVIC-8561041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV2926-SOtherBOARD SOCIAL WORK LICENSE NUMBER
NVIC-856OtherSOCIAL WORK CSW NUMBER