Provider Demographics
NPI:1487375598
Name:KUEPPERS, JACOB
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:KUEPPERS
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 1:8191 SHORT TRACT RD
Mailing Address - Street 2:
Mailing Address - City:NUNDA
Mailing Address - State:NY
Mailing Address - Zip Code:14517-9722
Mailing Address - Country:US
Mailing Address - Phone:585-748-7700
Mailing Address - Fax:
Practice Address - Street 1:45 MAPLE ST
Practice Address - Street 2:
Practice Address - City:DANSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14437-9182
Practice Address - Country:US
Practice Address - Phone:585-335-5052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-07
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY798004163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY161039939OtherALL OTHER INSURANCES
NY161039939Medicaid