Healthcare Provider Details

I. General information

NPI: 1215850813
Provider Name (Legal Business Name): JOVANNA ROSE KUPETZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2026
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 10TH AVE
SHALIMAR FL
32579-1340
US

IV. Provider business mailing address

5308 CAVALIER DR
CRESTVIEW FL
32539-8689
US

V. Phone/Fax

Practice location:
  • Phone: 850-362-6824
  • Fax:
Mailing address:
  • Phone: 448-288-7727
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: