Provider Demographics
NPI:1790784643
Name:COPELAND, JERRELLE M (MD)
Entity Type:Individual
Prefix:DR
First Name:JERRELLE
Middle Name:M
Last Name:COPELAND
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6788 S KINGS RANCH RD
Mailing Address - Street 2:STE 1
Mailing Address - City:GOLD CANYON
Mailing Address - State:AZ
Mailing Address - Zip Code:85118-2928
Mailing Address - Country:US
Mailing Address - Phone:480-626-4999
Mailing Address - Fax:480-304-3239
Practice Address - Street 1:6788 S KINGS RANCH RD STE 1
Practice Address - Street 2:
Practice Address - City:GOLD CANYON
Practice Address - State:AZ
Practice Address - Zip Code:85118-2928
Practice Address - Country:US
Practice Address - Phone:480-626-4999
Practice Address - Fax:480-304-3239
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ25933207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ404723Medicaid
AZF23967Medicare UPIN
AZZ21888Medicare PIN
AZ404723Medicaid
AZ110180591Medicare PIN