Provider Demographics
NPI:1073329397
Name:JESSUP, EMMA MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:EMMA
Middle Name:MARIE
Last Name:JESSUP
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:EMMA
Other - Middle Name:MARIE
Other - Last Name:FISCHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:255 TREE LINE DR
Mailing Address - Street 2:
Mailing Address - City:OAK GROVE
Mailing Address - State:KY
Mailing Address - Zip Code:42262-7200
Mailing Address - Country:US
Mailing Address - Phone:608-513-8892
Mailing Address - Fax:
Practice Address - Street 1:5979 DESERT STORM AVE
Practice Address - Street 2:
Practice Address - City:FORT CAMPBELL
Practice Address - State:KY
Practice Address - Zip Code:42223-5514
Practice Address - Country:US
Practice Address - Phone:270-798-4677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-10
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant