Healthcare Provider Details

I. General information

NPI: 1508294687
Provider Name (Legal Business Name): JACQUELYN CHANDLER RUPP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2013
Last Update Date: 10/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2015 RANDOLPH RD SUITE 208
CHARLOTTE NC
28207-1128
US

IV. Provider business mailing address

13808 PROFESSIONAL CENTER DR
HUNTERSVILLE NC
28078-7948
US

V. Phone/Fax

Practice location:
  • Phone: 704-377-4009
  • Fax:
Mailing address:
  • Phone: 704-377-4009
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberL0030016
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: