MEDICARE: BRYN W. JESSUP, PHD, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)		IL

General Provider Information

NPI Number	:	1235357849
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRYN W. JESSUP, PHD, PC

Provider Business Mailing Address
First Line	:	778 W FRONTAGE RD
Second Line	:	SUITE 114
City	:	NORTHFIELD
State	:	IL
Zip	:	60093-1209
Country	:	US
Telephone Number	:	847-501-5897
Fax Number	:	847-501-5896

Provider Business Practice Location Address
First Line	:	778 W FRONTAGE RD
Second Line	:	SUITE 114
City	:	NORTHFIELD
State	:	IL
Zip	:	60093-1209
Country	:	US
Telephone Number	:	847-501-5897
Fax Number	:	847-501-5896

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. BRYN W. JESSUP
Credential	:	PH.D.
Telephone Number	:	847-501-5897

Provider Enumeration Date	:	04/22/2007
Last Update Date	:	08/22/2020

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