Provider Demographics
NPI:1265716740
Name:JESSUP, SHAWN D
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:D
Last Name:JESSUP
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 HOLLY TREE RD
Mailing Address - Street 2:
Mailing Address - City:CLAUDVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24076-3351
Mailing Address - Country:US
Mailing Address - Phone:540-392-8198
Mailing Address - Fax:
Practice Address - Street 1:1131 RANDOLPH ST
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:NC
Practice Address - Zip Code:27360-5749
Practice Address - Country:US
Practice Address - Phone:336-474-8900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-03
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC241561835P1200X, 183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy
No183500000XPharmacy Service ProvidersPharmacist