Provider Demographics
NPI:1902821044
Name:COOPERSMITH, JERALD GLENN (ARNP)
Entity Type:Individual
Prefix:MR
First Name:JERALD
Middle Name:GLENN
Last Name:COOPERSMITH
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 RENWORTH LN
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32164-6627
Mailing Address - Country:US
Mailing Address - Phone:386-586-5314
Mailing Address - Fax:
Practice Address - Street 1:1955 US HIGHWAY 1 S
Practice Address - Street 2:200
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-3708
Practice Address - Country:US
Practice Address - Phone:904-829-8956
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9218067363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily