Provider Demographics
NPI:1790776722
Name:COOPER, JANE M (NP)
Entity Type:Individual
Prefix:MRS
First Name:JANE
Middle Name:M
Last Name:COOPER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 608
Mailing Address - Street 2:
Mailing Address - City:MCCLELLANVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29458-0608
Mailing Address - Country:US
Mailing Address - Phone:843-887-3274
Mailing Address - Fax:843-887-3929
Practice Address - Street 1:1189 TIBWIN ROAD
Practice Address - Street 2:
Practice Address - City:MCCLELLANVILLE
Practice Address - State:SC
Practice Address - Zip Code:29458-9405
Practice Address - Country:US
Practice Address - Phone:843-887-3274
Practice Address - Fax:843-887-3929
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2017-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCF3048363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0364690Medicaid
MANP3875Medicare ID - Type Unspecified
MA0364690Medicaid