Provider Demographics
NPI:1417408592
Name:COOPER, JAMIE LYNN (DPT)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:LYNN
Last Name:COOPER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:JAMIE
Other - Middle Name:LYNN
Other - Last Name:LOSENBECK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:1790 SW 43RD WAY
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33317-5701
Mailing Address - Country:US
Mailing Address - Phone:855-442-2454
Mailing Address - Fax:954-206-7699
Practice Address - Street 1:1790 SW 43RD WAY
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33317-5701
Practice Address - Country:US
Practice Address - Phone:855-442-2454
Practice Address - Fax:954-206-7699
Is Sole Proprietor?:No
Enumeration Date:2016-10-24
Last Update Date:2017-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT285262251P0200X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019111000Medicaid