Healthcare Provider Details

I. General information

NPI: 1376528885
Provider Name (Legal Business Name): MARGARET ANN JESSOP PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/07/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

53700 GENERATIONS DR SUITE 200
SOUTH BEND IN
46635-1539
US

IV. Provider business mailing address

53700 GENERATIONS DR SUITE 200
SOUTH BEND IN
46635-1539
US

V. Phone/Fax

Practice location:
  • Phone: 574-235-3026
  • Fax:
Mailing address:
  • Phone: 574-235-3026
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPSY 18255
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number20041913A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: