Provider Demographics
NPI:1225536279
Name:COOPER, JOSHUA DYLAN (DC, LMT, CA)
Entity Type:Individual
Prefix:DR
First Name:JOSHUA
Middle Name:DYLAN
Last Name:COOPER
Suffix:
Gender:M
Credentials:DC, LMT, CA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19206 SE 1ST ST STE 118
Mailing Address - Street 2:
Mailing Address - City:CAMAS
Mailing Address - State:WA
Mailing Address - Zip Code:98607-7478
Mailing Address - Country:US
Mailing Address - Phone:360-433-9016
Mailing Address - Fax:360-433-9809
Practice Address - Street 1:19206 SE 1ST ST STE 118
Practice Address - Street 2:
Practice Address - City:CAMAS
Practice Address - State:WA
Practice Address - Zip Code:98607-7478
Practice Address - Country:US
Practice Address - Phone:360-433-9809
Practice Address - Fax:360-433-9809
Is Sole Proprietor?:No
Enumeration Date:2018-01-24
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR19927225700000X
WACH60883035111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1225536279Medicaid