Healthcare Provider Details

I. General information

NPI: 1497517627
Provider Name (Legal Business Name): MRS. KRISTINE MICHELLE JESSUP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2024
Last Update Date: 01/24/2024
Certification Date: 01/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 FRONT ST STE 1
BINGHAMTON NY
13905-2448
US

IV. Provider business mailing address

225 FRONT ST STE 1
BINGHAMTON NY
13905-2448
US

V. Phone/Fax

Practice location:
  • Phone: 607-778-3930
  • Fax: 607-778-2838
Mailing address:
  • Phone: 607-778-3930
  • Fax: 607-778-2838

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: