Provider Demographics
NPI:1356457576
Name:COOPER, JASON ANDRE (ATC, PTA)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:ANDRE
Last Name:COOPER
Suffix:
Gender:M
Credentials:ATC, PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 S. MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:WATER VALLEY
Mailing Address - State:MS
Mailing Address - Zip Code:38965
Mailing Address - Country:US
Mailing Address - Phone:662-473-3400
Mailing Address - Fax:662-473-4389
Practice Address - Street 1:214 EAST MAIN ST.
Practice Address - Street 2:
Practice Address - City:SENATOBIA
Practice Address - State:MS
Practice Address - Zip Code:38668
Practice Address - Country:US
Practice Address - Phone:662-560-0602
Practice Address - Fax:662-560-0603
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSAT03262255A2300X
2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer