Provider Demographics
NPI:1053840413
Name:LUPTON, JACQUELINE ANNE (LAT, ATC)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:ANNE
Last Name:LUPTON
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:MS
Other - First Name:JACQUELINE
Other - Middle Name:ANNE
Other - Last Name:LLOYD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAT, ATC
Mailing Address - Street 1:824 STILLWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31419-2643
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:824 STILLWOOD DR
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31419-2643
Practice Address - Country:US
Practice Address - Phone:912-961-8764
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-08
Last Update Date:2023-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO20000281132255A2300X
GAAT004124207PS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PS0010XAllopathic & Osteopathic PhysiciansEmergency MedicineSports Medicine
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer