Provider Demographics
NPI:1659405512
Name:JUPP, ROBERTA O'CONNOR (RD)
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:O'CONNOR
Last Name:JUPP
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:723 ELLIPTIC GREEN LN
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29073-7057
Mailing Address - Country:US
Mailing Address - Phone:803-622-9104
Mailing Address - Fax:803-728-3224
Practice Address - Street 1:147 VERA RD STE E
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-3756
Practice Address - Country:US
Practice Address - Phone:803-399-0212
Practice Address - Fax:803-728-3224
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC726464133V00000X
SC131133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDPE012Medicaid