Basic Information
| Provider Information | |||||||||
| NPI: | 1699315119 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JESSUP | ||||||||
| FirstName: | CARRIE | ||||||||
| MiddleName: | FRANCES | ||||||||
| NamePrefix: | |||||||||
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| Credential: | MS ED | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ARSENAULT | ||||||||
| OtherFirstName: | CARRIE | ||||||||
| OtherMiddleName: | FRANCES | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 321 EVANS ST APT E | ||||||||
| Address2: | |||||||||
| City: | WILLIAMSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142215630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7165660810 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4242 RIDGE LEA RD STE 2 | ||||||||
| Address2: | |||||||||
| City: | AMHERST | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142265122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168192400 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/13/2020 | ||||||||
| LastUpdateDate: | 01/13/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 222Q00000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Developmental Therapist |
No ID Information.