Healthcare Provider Details

I. General information

NPI: 1972504645
Provider Name (Legal Business Name): NEAL S JESSUP O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2005
Last Update Date: 06/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2205 ORANGE AVE NE
ROANOKE VA
24012-8305
US

IV. Provider business mailing address

PO BOX 488
VINTON VA
24179-0488
US

V. Phone/Fax

Practice location:
  • Phone: 540-343-2197
  • Fax: 540-343-3575
Mailing address:
  • Phone: 540-343-2197
  • Fax: 540-343-3575

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0601001553
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: