Provider Demographics
NPI:1639609415
Name:COOPER, JESSICA ANNE (LCSWA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ANNE
Last Name:COOPER
Suffix:
Gender:F
Credentials:LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:702 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ROXBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27573-4755
Mailing Address - Country:US
Mailing Address - Phone:336-599-9271
Mailing Address - Fax:336-599-0347
Practice Address - Street 1:702 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ROXBORO
Practice Address - State:NC
Practice Address - Zip Code:27573-4755
Practice Address - Country:US
Practice Address - Phone:336-599-9271
Practice Address - Fax:336-599-0347
Is Sole Proprietor?:No
Enumeration Date:2017-06-14
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0123191041C0700X
NCP0116681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1639609415Medicaid