Provider Demographics
NPI:1073064226
Name:COOPER, THEAVIS JR (ATC)
Entity Type:Individual
Prefix:MR
First Name:THEAVIS
Middle Name:
Last Name:COOPER
Suffix:JR
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:507 HIGHWAY 51 N
Mailing Address - Street 2:PO BOX 948
Mailing Address - City:BROOKHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:39601
Mailing Address - Country:US
Mailing Address - Phone:601-754-8008
Mailing Address - Fax:
Practice Address - Street 1:1028 JC REDD DR WESSON, MISSISSIPPI 39191
Practice Address - Street 2:
Practice Address - City:WESSON
Practice Address - State:MS
Practice Address - Zip Code:39191
Practice Address - Country:US
Practice Address - Phone:601-643-8479
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-21
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer