Provider Demographics
NPI:1750859104
Name:COPPOLA, JADE VICTORIA (PA-C)
Entity Type:Individual
Prefix:
First Name:JADE
Middle Name:VICTORIA
Last Name:COPPOLA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 CARTER RUN CT
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29681-6573
Mailing Address - Country:US
Mailing Address - Phone:203-214-0453
Mailing Address - Fax:
Practice Address - Street 1:605 E FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:HARTWELL
Practice Address - State:GA
Practice Address - Zip Code:30643-7301
Practice Address - Country:US
Practice Address - Phone:706-376-6200
Practice Address - Fax:706-376-6488
Is Sole Proprietor?:No
Enumeration Date:2018-11-04
Last Update Date:2019-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA9274363AM0700X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant