Provider Demographics
NPI:1598981169
Name:COOPER, JOE B
Entity Type:Individual
Prefix:
First Name:JOE
Middle Name:B
Last Name:COOPER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 WESTWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38301-4324
Mailing Address - Country:US
Mailing Address - Phone:731-217-0276
Mailing Address - Fax:
Practice Address - Street 1:306 WESTWOOD AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-4324
Practice Address - Country:US
Practice Address - Phone:731-217-0276
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2009-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN9471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1505295Medicaid
TN4158899OtherBCBS
TN4158899OtherBCBS