Healthcare Provider Details

I. General information

NPI: 1871585380
Provider Name (Legal Business Name): ROBERT PAUL JESSUP L.P.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/19/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4656 BRAMBLETON AVE
ROANOKE VA
24018-3437
US

IV. Provider business mailing address

4656 BRAMBLETON AVE
ROANOKE VA
24018-3437
US

V. Phone/Fax

Practice location:
  • Phone: 540-772-8043
  • Fax: 540-772-8242
Mailing address:
  • Phone: 540-772-8043
  • Fax: 540-772-8242

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701003069
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: