Provider Demographics
NPI:1598577215
Name:CUPP, JACKLYN JEAN
Entity type:Individual
Prefix:
First Name:JACKLYN
Middle Name:JEAN
Last Name:CUPP
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9940 TALBERT AVE # 101
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-5153
Mailing Address - Country:US
Mailing Address - Phone:714-545-8700
Mailing Address - Fax:
Practice Address - Street 1:101 BUCKNELL AVE UNIT 345
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:CA
Practice Address - Zip Code:91711-4944
Practice Address - Country:US
Practice Address - Phone:714-310-2025
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-21
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant