Provider Demographics
NPI:1790255669
Name:ROUBIC, COOPER JORDAN
Entity Type:Individual
Prefix:
First Name:COOPER
Middle Name:JORDAN
Last Name:ROUBIC
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 1:10802 FOREST ST
Mailing Address - Street 2:
Mailing Address - City:GARRETTSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44231-1079
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10802 FOREST ST APT 22
Practice Address - Street 2:
Practice Address - City:GARRETTSVILLE
Practice Address - State:OH
Practice Address - Zip Code:44231-1077
Practice Address - Country:US
Practice Address - Phone:330-978-6561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-04
Last Update Date:2018-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Single Specialty