Provider Demographics
NPI:1083857445
Name:COPLEY, JACK ALAN (DMIN, LMFT, IMFT)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:ALAN
Last Name:COPLEY
Suffix:
Gender:M
Credentials:DMIN, LMFT, IMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3927 EILEEN DR
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45209-2014
Mailing Address - Country:US
Mailing Address - Phone:304-205-0695
Mailing Address - Fax:
Practice Address - Street 1:1714 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:KY
Practice Address - Zip Code:41008-8775
Practice Address - Country:US
Practice Address - Phone:502-732-9331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-15
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY08-029101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY610661458OtherTAX ID NUMBER