Provider Demographics
NPI:1568479350
Name:LUPO, JESSICA DE MARIE (DC)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:DE MARIE
Last Name:LUPO
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27850 GRATIOT AVE
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066-4803
Mailing Address - Country:US
Mailing Address - Phone:586-772-5876
Mailing Address - Fax:586-772-1122
Practice Address - Street 1:27850 GRATIOT AVE
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-4803
Practice Address - Country:US
Practice Address - Phone:586-772-5876
Practice Address - Fax:586-772-1122
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301008650111N00000X, 225100000X, 111NX0100X, 111NI0013X, 111NR0400X, 111NP0017X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No111NX0100XChiropractic ProvidersChiropractorOccupational Health
No111NI0013XChiropractic ProvidersChiropractorIndependent Medical Examiner
No111NR0400XChiropractic ProvidersChiropractorRehabilitation
No111NP0017XChiropractic ProvidersChiropractorPediatric Chiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIJL008650OtherBLUE CROSS BLUE SHIELD
MI2301008650OtherBCBS MI
MIP00378726OtherRAILROAD MEDICARE
MI40734OtherHEALTH PLAN OF MICHIGAN
MI152231OtherGREAT LAKES HEALTH PLAN
MI4803210Medicaid
MI4803210Medicaid
0N23370008Medicare PIN