Provider Demographics
NPI:1366010464
Name:ROUPE, JESSICA D (RBT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:D
Last Name:ROUPE
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:HACKWORTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3005 SW PARK AVE
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-7902
Mailing Address - Country:US
Mailing Address - Phone:580-699-5558
Mailing Address - Fax:580-699-5559
Practice Address - Street 1:3005 SW PARK AVE
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-7902
Practice Address - Country:US
Practice Address - Phone:580-699-5558
Practice Address - Fax:580-699-5559
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-15
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT21171568106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician