Provider Demographics
NPI:1831223767
Name:KUPPER, JACQUELINE (LMSW)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:KUPPER
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:
Other - Last Name:RILEY-KUPPER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:19337 MELVIN ST
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066-2626
Mailing Address - Country:US
Mailing Address - Phone:586-219-1973
Mailing Address - Fax:
Practice Address - Street 1:11270 E 13 MILE RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-2599
Practice Address - Country:US
Practice Address - Phone:586-738-9320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010884351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical