Provider Demographics
NPI:1750857850
Name:KOPEC, JASON
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:KOPEC
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 1:1320 WALDO AVE
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48642-5898
Mailing Address - Country:US
Mailing Address - Phone:989-280-8697
Mailing Address - Fax:
Practice Address - Street 1:1320 WALDO AVE
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48642-5898
Practice Address - Country:US
Practice Address - Phone:989-280-8697
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-17
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704310949363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily