Provider Demographics
NPI:1295597649
Name:UPCHURCH, JACK
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:UPCHURCH
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 1:107 LARK LN
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27712-2430
Mailing Address - Country:US
Mailing Address - Phone:919-698-6698
Mailing Address - Fax:
Practice Address - Street 1:7980 CHAPEL HILL RD STE 135
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27513-4649
Practice Address - Country:US
Practice Address - Phone:919-377-2395
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-30
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician