Provider Demographics
NPI:1659725117
Name:COOPER, JORDAN
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
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 1:1401 APPLEWOOD DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720-2699
Mailing Address - Country:US
Mailing Address - Phone:706-270-5033
Mailing Address - Fax:706-370-7749
Practice Address - Street 1:2615 CLEVELAND HWY
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30721-8160
Practice Address - Country:US
Practice Address - Phone:706-270-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-20
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator