Provider Demographics
NPI:1023557618
Name:UPCHURCH, JEROME J (SA-C, CSFA)
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:J
Last Name:UPCHURCH
Suffix:
Gender:M
Credentials:SA-C, CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15811 CHAGALL TER
Mailing Address - Street 2:
Mailing Address - City:NORTH POTOMAC
Mailing Address - State:MD
Mailing Address - Zip Code:20878-3461
Mailing Address - Country:US
Mailing Address - Phone:215-518-2138
Mailing Address - Fax:
Practice Address - Street 1:15811 CHAGALL TER
Practice Address - Street 2:
Practice Address - City:NORTH POTOMAC
Practice Address - State:MD
Practice Address - Zip Code:20878-3461
Practice Address - Country:US
Practice Address - Phone:215-518-2138
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-16
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical AssistantGroup - Multi-Specialty