Provider Demographics
NPI:1164016879
Name:COOPER-BRACY, JAMIE ATHELA
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:ATHELA
Last Name:COOPER-BRACY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13846 STATE ROUTE 613
Mailing Address - Street 2:
Mailing Address - City:VAN BUREN
Mailing Address - State:OH
Mailing Address - Zip Code:45889-9715
Mailing Address - Country:US
Mailing Address - Phone:419-889-5217
Mailing Address - Fax:
Practice Address - Street 1:13846 STATE ROUTE 613
Practice Address - Street 2:
Practice Address - City:VAN BUREN
Practice Address - State:OH
Practice Address - Zip Code:45889-9715
Practice Address - Country:US
Practice Address - Phone:419-889-5217
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-23
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3202635376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376J00000XNursing Service Related ProvidersHomemakerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3202635Medicaid