Provider Demographics
NPI:1417664475
Name:COOPER, DEJA
Entity Type:Individual
Prefix:
First Name:DEJA
Middle Name:
Last Name:COOPER
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 1:200 ASSOCIATION DR STE 130
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25311-1277
Mailing Address - Country:US
Mailing Address - Phone:304-988-4200
Mailing Address - Fax:
Practice Address - Street 1:200 ASSOCIATION DR STE 130
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25311-1277
Practice Address - Country:US
Practice Address - Phone:304-988-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-31
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker