Provider Demographics
NPI:1811170632
Name:JESSUP, JODY S (MS, LPC, RD)
Entity type:Individual
Prefix:MISS
First Name:JODY
Middle Name:S
Last Name:JESSUP
Suffix:
Gender:F
Credentials:MS, LPC, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 N 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:STURGEON BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54235-1249
Mailing Address - Country:US
Mailing Address - Phone:920-743-9554
Mailing Address - Fax:
Practice Address - Street 1:620 N 12TH AVE
Practice Address - Street 2:
Practice Address - City:STURGEON BAY
Practice Address - State:WI
Practice Address - Zip Code:54235-1249
Practice Address - Country:US
Practice Address - Phone:920-743-9554
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-14
Last Update Date:2007-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43727200Medicaid