Healthcare Provider Details

I. General information

NPI: 1922298686
Provider Name (Legal Business Name): MILDRED WHITE JESSUP RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2007
Last Update Date: 07/30/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2023 S 17TH ST
WILMINGTON NC
28401-6600
US

IV. Provider business mailing address

2023 S 17TH ST
WILMINGTON NC
28401-6600
US

V. Phone/Fax

Practice location:
  • Phone: 910-251-6550
  • Fax:
Mailing address:
  • Phone: 910-251-6550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License Number044008
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number044008
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number044008
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: