Provider Demographics
NPI:1043565708
Name:DUNGAN, JODY COOPER
Entity Type:Individual
Prefix:DR
First Name:JODY
Middle Name:COOPER
Last Name:DUNGAN
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 1:25 MEDPARK SQUARE DR STE 4
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42503-1708
Mailing Address - Country:US
Mailing Address - Phone:205-412-3863
Mailing Address - Fax:
Practice Address - Street 1:25 MEDPARK SQUARE DR STE 4
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503-1708
Practice Address - Country:US
Practice Address - Phone:205-412-3863
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-18
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY016075183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist