Provider Demographics
NPI:1558047084
Name:COOPER, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
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 1:118 ROYAL OAK DR
Mailing Address - Street 2:
Mailing Address - City:GUYTON
Mailing Address - State:GA
Mailing Address - Zip Code:31312-5624
Mailing Address - Country:US
Mailing Address - Phone:912-665-7471
Mailing Address - Fax:
Practice Address - Street 1:118 ROYAL OAK DR
Practice Address - Street 2:
Practice Address - City:GUYTON
Practice Address - State:GA
Practice Address - Zip Code:31312-5624
Practice Address - Country:US
Practice Address - Phone:912-665-7471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-27
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLPA0004572355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant