Provider Demographics
NPI:1891240495
Name:JACK D COOPER
Entity Type:Organization
Organization Name:JACK D COOPER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KAYLA
Authorized Official - Middle Name:C
Authorized Official - Last Name:KOBS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-944-3305
Mailing Address - Street 1:705 N 17TH AVE
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68003-1209
Mailing Address - Country:US
Mailing Address - Phone:402-944-3305
Mailing Address - Fax:402-944-7611
Practice Address - Street 1:705 N 17TH AVE
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:NE
Practice Address - Zip Code:68003-1209
Practice Address - Country:US
Practice Address - Phone:402-944-3305
Practice Address - Fax:402-944-7611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-24
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE40051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty