Healthcare Provider Details

I. General information

NPI: 1831223767
Provider Name (Legal Business Name): JACQUELINE KUPPER LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JACQUELINE RILEY-KUPPER LMSW

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 12/12/2019
Certification Date: 12/12/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11270 E 13 MILE RD
WARREN MI
48093-2599
US

IV. Provider business mailing address

19337 MELVIN ST
ROSEVILLE MI
48066-2626
US

V. Phone/Fax

Practice location:
  • Phone: 586-738-9320
  • Fax:
Mailing address:
  • Phone: 586-219-1973
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801088435
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: