Provider Demographics
NPI:1568906246
Name:COPPOCK, JESSICA (CRNA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:COPPOCK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11033 WOODSON RD
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:KS
Mailing Address - Zip Code:67356-8701
Mailing Address - Country:US
Mailing Address - Phone:620-778-2297
Mailing Address - Fax:
Practice Address - Street 1:B430 KU HOSPITAL
Practice Address - Street 2:MAIL STOP 4022 3901 RAINBOW BLVD
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66160-0001
Practice Address - Country:US
Practice Address - Phone:913-588-6673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-14
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS114199367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered