Provider Demographics
NPI:1578114419
Name:COOPER, TIFFANY DANIELLE (CHILD CIS)
Entity Type:Individual
Prefix:MS
First Name:TIFFANY
Middle Name:DANIELLE
Last Name:COOPER
Suffix:
Gender:F
Credentials:CHILD CIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2707 BROWNS LN
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-7213
Mailing Address - Country:US
Mailing Address - Phone:870-972-4939
Mailing Address - Fax:
Practice Address - Street 1:209 S LOCKARD ST
Practice Address - Street 2:
Practice Address - City:BLYTHEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72315-2541
Practice Address - Country:US
Practice Address - Phone:870-763-2139
Practice Address - Fax:870-763-5056
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-23
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator