Provider Demographics
NPI:1083136550
Name:COOPER, MEGAN S (LMT)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:S
Last Name:COOPER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14985 OLD SAINT AUGUSTINE RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32258-9477
Mailing Address - Country:US
Mailing Address - Phone:904-288-9491
Mailing Address - Fax:
Practice Address - Street 1:14985 OLD SAINT AUGUSTINE RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-9477
Practice Address - Country:US
Practice Address - Phone:904-858-7045
Practice Address - Fax:904-858-7047
Is Sole Proprietor?:No
Enumeration Date:2017-07-17
Last Update Date:2017-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA72262225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist