Provider Demographics
NPI:1619695723
Name:COOPER, JASON MATTHEW
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:MATTHEW
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 1:1690 BELTLINE RD SW STE 2
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35601-5505
Mailing Address - Country:US
Mailing Address - Phone:256-607-1947
Mailing Address - Fax:800-607-1947
Practice Address - Street 1:1690 BELTLINE RD SW STE 2
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:AL
Practice Address - Zip Code:35601-5505
Practice Address - Country:US
Practice Address - Phone:256-607-1947
Practice Address - Fax:800-607-1947
Is Sole Proprietor?:No
Enumeration Date:2022-08-16
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALRBT-22-230026106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician