Healthcare Provider Details

I. General information

NPI: 1518927789
Provider Name (Legal Business Name): DAVID MILLER JESSUP MS, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 S ODELL ST
BROWNSBURG IN
46112-1929
US

IV. Provider business mailing address

2 LACY CT
BROWNSBURG IN
46112-2033
US

V. Phone/Fax

Practice location:
  • Phone: 317-852-2258
  • Fax: 317-852-1495
Mailing address:
  • Phone: 317-852-9651
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36000085A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: