Provider Demographics
NPI:1497077424
Name:COOPER, BOBBY JEAN
Entity Type:Individual
Prefix:MRS
First Name:BOBBY
Middle Name:JEAN
Last Name:COOPER
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:BOBBY
Other - Middle Name:JEAN
Other - Last Name:COOPER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMHC
Mailing Address - Street 1:12309 BRETON OAK LN
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33569-8227
Mailing Address - Country:US
Mailing Address - Phone:813-245-5549
Mailing Address - Fax:
Practice Address - Street 1:12309 BRETON OAK LN
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33569-8227
Practice Address - Country:US
Practice Address - Phone:813-245-5549
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-17
Last Update Date:2010-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH 9004101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health