Healthcare Provider Details

I. General information

NPI: 1598577215
Provider Name (Legal Business Name): JACKLYN JEAN CUPP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/21/2025
Last Update Date: 02/20/2025
Certification Date: 02/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 BUCKNELL AVE UNIT 345
CLAREMONT CA
91711-4944
US

IV. Provider business mailing address

9940 TALBERT AVE # 101
FOUNTAIN VALLEY CA
92708-5153
US

V. Phone/Fax

Practice location:
  • Phone: 714-310-2025
  • Fax:
Mailing address:
  • Phone: 714-545-8700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: