Provider Demographics
NPI:1164724415
Name:KUPPER, JACKIE LYNN (MS, CRC, LCAS, LPCA)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:LYNN
Last Name:KUPPER
Suffix:
Gender:F
Credentials:MS, CRC, LCAS, LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2705 CARLISLE COURT
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27858-5536
Mailing Address - Country:US
Mailing Address - Phone:252-560-3740
Mailing Address - Fax:
Practice Address - Street 1:150 E ARLINGTON BLVD SUITE E.
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27858-5019
Practice Address - Country:US
Practice Address - Phone:252-321-1568
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-18
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC00111147101Y00000X
NC1581101YA0400X
NCA8786101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional