Provider Demographics
NPI:1548581218
Name:COOPER, JESSICA ROSE (CNP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ROSE
Last Name:COOPER
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 PRESTIGE PL STE 550
Mailing Address - Street 2:
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-6115
Mailing Address - Country:US
Mailing Address - Phone:937-762-1310
Mailing Address - Fax:375-228-0689
Practice Address - Street 1:6438 WILMINGTON PIKE STE 300
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-7021
Practice Address - Country:US
Practice Address - Phone:937-848-4850
Practice Address - Fax:937-848-4858
Is Sole Proprietor?:No
Enumeration Date:2010-06-17
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.10960 NP363LW0102X
OHAPRN.CNP.10960364SW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SW0102XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistWomen's Health
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3055232Medicaid