Provider Demographics
NPI:1982164331
Name:TRIPP, JACQUELYN
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:
Last Name:TRIPP
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2097 ELMORE AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43224-5020
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1435 E MAIN ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43205-2035
Practice Address - Country:US
Practice Address - Phone:216-540-1358
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-21
Last Update Date:2019-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty