Provider Demographics
NPI:1932156288
Name:JESSUP, VONNIE L
Entity Type:Individual
Prefix:
First Name:VONNIE
Middle Name:L
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 1:231 DARCY AVE
Mailing Address - Street 2:
Mailing Address - City:GOOSE CREEK
Mailing Address - State:SC
Mailing Address - Zip Code:29445-6693
Mailing Address - Country:US
Mailing Address - Phone:843-452-2955
Mailing Address - Fax:
Practice Address - Street 1:105 CENTRAL AVE UNIT 11
Practice Address - Street 2:
Practice Address - City:GOOSE CREEK
Practice Address - State:SC
Practice Address - Zip Code:29445-3269
Practice Address - Country:US
Practice Address - Phone:843-452-2955
Practice Address - Fax:843-640-3568
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-30
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4806101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health