Provider Demographics
NPI:1508294687
Name:RUPP, JACQUELYN CHANDLER
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:CHANDLER
Last Name:RUPP
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13808 PROFESSIONAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:HUNTERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28078-7948
Mailing Address - Country:US
Mailing Address - Phone:704-377-4009
Mailing Address - Fax:
Practice Address - Street 1:2015 RANDOLPH RD
Practice Address - Street 2:SUITE 208
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1128
Practice Address - Country:US
Practice Address - Phone:704-377-4009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-28
Last Update Date:2013-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL0030016133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered