Provider Demographics
NPI:1932552841
Name:JESSUP, TIANA (MS)
Entity Type:Individual
Prefix:
First Name:TIANA
Middle Name:
Last Name:JESSUP
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3629 PEARLBUSH AVE
Mailing Address - Street 2:APT 2
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46203-6704
Mailing Address - Country:US
Mailing Address - Phone:317-540-0373
Mailing Address - Fax:
Practice Address - Street 1:3629 PEARLBUSH AVE
Practice Address - Street 2:APT 2
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46203-6704
Practice Address - Country:US
Practice Address - Phone:317-540-0373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-14
Last Update Date:2017-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171W00000XOther Service ProvidersContractor