Provider Demographics
NPI:1427535079
Name:COOPER, JENNA JOE ROSE (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:JOE ROSE
Last Name:COOPER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2204 JEFFERSON DAVIS DR
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-5222
Mailing Address - Country:US
Mailing Address - Phone:662-316-6133
Mailing Address - Fax:
Practice Address - Street 1:2204 JEFFERSON DAVIS DR
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-5222
Practice Address - Country:US
Practice Address - Phone:662-316-6133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-26
Last Update Date:2018-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPA00382207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology