=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467592295
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EVA LYNN JESSUP DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/08/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2221 CLEARVIEW PKWY STE 202
-----------------------------------------------------
City | METAIRIE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70001-2481
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 504-455-1667
-----------------------------------------------------
Fax | 504-455-1783
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2221 CLEARVIEW PKWY STE 202
-----------------------------------------------------
City | METAIRIE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70001-2481
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 504-455-1667
-----------------------------------------------------
Fax | 504-455-1783
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 5030
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------