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General NPI Number Information
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NPI Number | 1346330107
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Entity Type | Individual
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Provider Name | KIMBERLY JESSUP
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Gender | Female
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Dates
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Enumeration Date | 10/13/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 115 LIBERTY ST
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City | BATH
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State | NY
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Zip | 14810-1508
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Country | US
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Telephone | 607-776-6577
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Fax |
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Provider Business Mailing Address
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Address Line | 4445 TUCKER RD # A
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City | CAMPBELL
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State | NY
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Zip | 14821-9744
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 11252
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License Number State | NY
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