Provider Demographics
NPI:1851650717
Name:SHUPLOCK, JACQUELINE MARIE (MD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:MARIE
Last Name:SHUPLOCK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:
Other - Last Name:KATTNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2501 N ORANGE AVE STE 310
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-4642
Mailing Address - Country:US
Mailing Address - Phone:407-303-2001
Mailing Address - Fax:407-303-2450
Practice Address - Street 1:2501 N ORANGE AVE STE 310
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804-4642
Practice Address - Country:US
Practice Address - Phone:407-303-2001
Practice Address - Fax:407-303-2450
Is Sole Proprietor?:No
Enumeration Date:2012-05-14
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD00000533382080P0202X
390200000X
FLME1522002080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program