Healthcare Provider Details

I. General information

NPI: 1649266800
Provider Name (Legal Business Name): JOHN N JESSUP NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2005
Last Update Date: 11/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E GENESEE ST SUITE 300
SYRACUSE NY
13210-1892
US

IV. Provider business mailing address

1000 E GENESEE ST SUITE 300
SYRACUSE NY
13210-1892
US

V. Phone/Fax

Practice location:
  • Phone: 315-471-1044
  • Fax: 315-474-4312
Mailing address:
  • Phone: 315-471-1044
  • Fax: 315-474-4312

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF332697
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberF-332697
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberF322697
License Number StateNY
# 4
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberF332697
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: