Provider Demographics
NPI:1790883429
Name:COOPER, JENNA RENEA (CRNP)
Entity Type:Individual
Prefix:MRS
First Name:JENNA
Middle Name:RENEA
Last Name:COOPER
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 KINGS MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35406-2735
Mailing Address - Country:US
Mailing Address - Phone:205-247-5302
Mailing Address - Fax:
Practice Address - Street 1:100 RICE MINE ROAD LOOP STE 301
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35406-2417
Practice Address - Country:US
Practice Address - Phone:205-247-5302
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-079436363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL515-31544OtherBLUECROSS/BLUESHIELD
AL891010700Medicaid
AL515-31417OtherBLUECROSS/BLUESHIELD
AL515-33037OtherBLUECROSS/BLUESHIELD
AL891010760Medicaid
AL891011330Medicaid
AL515-32587OtherBLUECROSS/BLUESHIELD
AL51532435OtherBLUECROSS/BLUESHIELD
AL891010770Medicaid
AL891010760Medicaid
AL0515-31544Medicare ID - Type Unspecified
AL515-31417OtherBLUECROSS/BLUESHIELD
ALP32656Medicare UPIN
AL051556969Medicare PIN
AL515-33037OtherBLUECROSS/BLUESHIELD