Provider Demographics
NPI:1679460745
Name:COOPER, JACQUELYN MARIE (LADAC II)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:MARIE
Last Name:COOPER
Suffix:
Gender:X
Credentials:LADAC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1809 FOREST RIDGE DR SW
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37311-7321
Mailing Address - Country:US
Mailing Address - Phone:423-599-2597
Mailing Address - Fax:
Practice Address - Street 1:1510 STUART RD NE STE 101
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37312-5869
Practice Address - Country:US
Practice Address - Phone:423-790-4906
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-21
Last Update Date:2025-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1730101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty