Provider Demographics
NPI:1790487163
Name:COOPER, JOE LEE JR (LLMSW)
Entity Type:Individual
Prefix:
First Name:JOE
Middle Name:LEE
Last Name:COOPER
Suffix:JR
Gender:M
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10332 SHAVER RD
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-6744
Mailing Address - Country:US
Mailing Address - Phone:269-743-7357
Mailing Address - Fax:
Practice Address - Street 1:10332 SHAVER RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-6744
Practice Address - Country:US
Practice Address - Phone:269-743-7357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-20
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68511084951041C0700X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health