=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457396251
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MELANIE JESSUP, DPM, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/17/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20415 NORTHVILLE PLACE DR #2308
-----------------------------------------------------
City | NORTHVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48167-2944
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-596-1548
-----------------------------------------------------
Fax | 248-596-1548
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20415 NORTHVILLE PLACE DR #2308
-----------------------------------------------------
City | NORTHVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48167-2944
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-596-1548
-----------------------------------------------------
Fax | 248-596-1548
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MELANIE R JESSUP
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 248-596-1548
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number | 5901002083
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------