Provider Demographics
NPI:1437443736
Name:LOPUCH, JEREMY JON
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:JON
Last Name:LOPUCH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20016 MULBERRY ST
Mailing Address - Street 2:
Mailing Address - City:CORNELIUS
Mailing Address - State:NC
Mailing Address - Zip Code:28031-8465
Mailing Address - Country:US
Mailing Address - Phone:704-560-1202
Mailing Address - Fax:
Practice Address - Street 1:20016 MULBERRY ST
Practice Address - Street 2:
Practice Address - City:CORNELIUS
Practice Address - State:NC
Practice Address - Zip Code:28031-8465
Practice Address - Country:US
Practice Address - Phone:704-560-1202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-03
Last Update Date:2011-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool