Provider Demographics
NPI:1598964280
Name:JESSUP, NANCY (LMFT)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:JESSUP
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2721 SHATTUCK AVE # 230
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94705-1008
Mailing Address - Country:US
Mailing Address - Phone:510-496-6044
Mailing Address - Fax:
Practice Address - Street 1:2711 ALCATRAZ AVE STE 5
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94705-2726
Practice Address - Country:US
Practice Address - Phone:510-496-6044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-13
Last Update Date:2013-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC47683106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist