Provider Demographics
NPI:1093007882
Name:COOPER, JENNA (LCSW-R)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:COOPER
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2021 GRAND CONCOURSE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10453-4304
Mailing Address - Country:US
Mailing Address - Phone:718-960-3413
Mailing Address - Fax:718-466-0481
Practice Address - Street 1:260 E 188TH ST FL 2
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10458-5302
Practice Address - Country:US
Practice Address - Phone:718-960-3413
Practice Address - Fax:718-960-9317
Is Sole Proprietor?:No
Enumeration Date:2011-05-11
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY083007-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY131740122Medicaid