Healthcare Provider Details

I. General information

NPI: 1518300144
Provider Name (Legal Business Name): JOHN PAGE JESSUP PSYCHOLOGIST, MA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JACK JESSUP MA, LP

II. Dates (important events)

Enumeration Date: 04/13/2013
Last Update Date: 06/17/2020
Certification Date: 06/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1085 US ROUTE 4 E STE 2A
RUTLAND VT
05701-8007
US

IV. Provider business mailing address

1085 US-4 EAST SUITE 2A
RUTLAND VT
05701
US

V. Phone/Fax

Practice location:
  • Phone: 802-417-2067
  • Fax:
Mailing address:
  • Phone: 802-417-2067
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number047.0123038
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number047.0123038
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: