Provider Demographics
NPI:1851772560
Name:COOPER, JACKQUELINE
Entity Type:Individual
Prefix:
First Name:JACKQUELINE
Middle Name:
Last Name:COOPER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2552 POPLAR AVE
Mailing Address - Street 2:4B
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38112-3852
Mailing Address - Country:US
Mailing Address - Phone:901-409-2849
Mailing Address - Fax:
Practice Address - Street 1:2552 POPLAR AVE
Practice Address - Street 2:4B
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38112-3852
Practice Address - Country:US
Practice Address - Phone:901-409-2849
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-18
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care