Healthcare Provider Details

I. General information

NPI: 1164724415
Provider Name (Legal Business Name): JACKIE LYNN KUPPER MS, CRC, LCAS, LPCA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2010
Last Update Date: 06/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 E ARLINGTON BLVD SUITE E.
GREENVILLE NC
27858-5019
US

IV. Provider business mailing address

2705 CARLISLE COURT
GREENVILLE NC
27858-5536
US

V. Phone/Fax

Practice location:
  • Phone: 252-321-1568
  • Fax:
Mailing address:
  • Phone: 252-560-3740
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number00111147
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1581
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberA8786
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: