Provider Demographics
NPI:1104982701
Name:JESSUP, JEFFREY CARR (OD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:CARR
Last Name:JESSUP
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:7091 OLD HARDING PIKE
Practice Address - Street 2:SUITE 105
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37221
Practice Address - Country:US
Practice Address - Phone:615-662-2800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNODT859152WC0802X
TN859152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0047504Medicaid
TN0792070001OtherMEDICARE DMERC PIN
TN202781012OtherTIN
TN0047504Medicaid
TN0792070001Medicare NSC
TN0792070001OtherMEDICARE DMERC PIN
TN103I416099Medicare PIN
TNT61223Medicare UPIN