Most Relevant Information
Provider Data
| NPI Number: | 1003328865 |
| Provider Name: | KEVIN JESSUP LAC |
| Entity Type: | Individual |
| Taxonomy Code: | 101YM0800X |
| Specialty: | Counselor |
| License Number: | LAC-14006 |
Most Important Dates
| Enumeration Date: | 11/01/2017 |
| Last Updated: | 11/01/2017 |
Provider Practice Location
4214 N 19TH PL
PHOENIX
AZ
850165427
Practice Location Phone/Fax
| Phone: | 6024605350 |
| Fax: |
Provider Mailing Location
4214 N 19TH PL
PHOENIX
AZ
850165427
Provider Mailing Phone/Fax
| Phone: | 6024605350 |
| Fax: |