Healthcare Provider Details

I. General information

NPI: 1598039901
Provider Name (Legal Business Name): JARRETT STEVEN CUPP LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2012
Last Update Date: 11/17/2022
Certification Date: 11/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

677 E. MAIN ST.
CENTREVILLE MI
49032
US

IV. Provider business mailing address

677 E. MAIN ST.
CENTREVILLE MI
49032
US

V. Phone/Fax

Practice location:
  • Phone: 269-467-1921
  • Fax: 269-979-7766
Mailing address:
  • Phone: 269-467-1921
  • Fax: 269-979-7766

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401018917
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: