Healthcare Provider Details

I. General information

NPI: 1649754318
Provider Name (Legal Business Name): SUZANNE JESSUP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2018
Last Update Date: 04/19/2023
Certification Date: 04/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1682 NOVATO BLVD
NOVATO CA
94947-7000
US

IV. Provider business mailing address

555 NORTHGATE DR
SAN RAFAEL CA
94903-3680
US

V. Phone/Fax

Practice location:
  • Phone: 415-473-2721
  • Fax:
Mailing address:
  • Phone: 415-526-7500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-FWQXYL
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: