Provider Demographics
NPI:1831527233
Name:JESSUP, AUDREY F
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:F
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 1:1471 DEER RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT AIRY
Mailing Address - State:NC
Mailing Address - Zip Code:27030-7407
Mailing Address - Country:US
Mailing Address - Phone:336-351-3401
Mailing Address - Fax:336-351-4344
Practice Address - Street 1:1471 DEER RD
Practice Address - Street 2:
Practice Address - City:MT AIRY
Practice Address - State:NC
Practice Address - Zip Code:27030-1471
Practice Address - Country:US
Practice Address - Phone:336-351-3401
Practice Address - Fax:336-351-4344
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-22
Last Update Date:2013-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1722320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities