Provider Demographics
NPI:1154305183
Name:COOPER, JENELLE L (MPT)
Entity Type:Individual
Prefix:MRS
First Name:JENELLE
Middle Name:L
Last Name:COOPER
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2327
Mailing Address - Street 2:
Mailing Address - City:LEONARDTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20650-8327
Mailing Address - Country:US
Mailing Address - Phone:301-997-1155
Mailing Address - Fax:
Practice Address - Street 1:40900 MERCHANTS LN
Practice Address - Street 2:
Practice Address - City:LEONARDTOWN
Practice Address - State:MD
Practice Address - Zip Code:20650-3795
Practice Address - Country:US
Practice Address - Phone:301-997-1155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD20634225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
61644501OtherBSMD
411592OtherMAMSI
58880008OtherBS DC
411592OtherMAMSI
MD674M202FMedicare PIN