Provider Demographics
NPI:1164054060
Name:COPPOLA, JENNIFER LAUREN (PHD, LMFT)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:LAUREN
Last Name:COPPOLA
Suffix:
Gender:F
Credentials:PHD, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4641 PAULI DR
Mailing Address - Street 2:
Mailing Address - City:MANLIUS
Mailing Address - State:NY
Mailing Address - Zip Code:13104-2419
Mailing Address - Country:US
Mailing Address - Phone:585-732-8852
Mailing Address - Fax:
Practice Address - Street 1:4500 PEWTER LN # 89
Practice Address - Street 2:
Practice Address - City:MANLIUS
Practice Address - State:NY
Practice Address - Zip Code:13104-9707
Practice Address - Country:US
Practice Address - Phone:315-414-9743
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-08
Last Update Date:2020-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001637106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist