Provider Demographics
NPI:1508231424
Name:COOPER, JENNIFER (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:COOPER
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10600 APHRODITE LOOP
Mailing Address - Street 2:APT 106
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34654-1753
Mailing Address - Country:US
Mailing Address - Phone:727-809-0247
Mailing Address - Fax:
Practice Address - Street 1:9540 TOWNE CENTRE DR
Practice Address - Street 2:SUITE 150
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-1988
Practice Address - Country:US
Practice Address - Phone:180-058-5129
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-03
Last Update Date:2015-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 14181235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist