Provider Demographics
NPI:1922127331
Name:COPAC INCORPORATED
Entity Type:Organization
Organization Name:COPAC INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JERALD
Authorized Official - Middle Name:STACY
Authorized Official - Last Name:HUGHES, JR.
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LPC
Authorized Official - Phone:601-829-2500
Mailing Address - Street 1:4309 LAKELAND DR
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-8947
Mailing Address - Country:US
Mailing Address - Phone:601-829-2500
Mailing Address - Fax:601-932-3857
Practice Address - Street 1:4309 LAKELAND DR
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-8947
Practice Address - Country:US
Practice Address - Phone:601-829-2500
Practice Address - Fax:601-932-3857
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSFS39-DADA-OP-01324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1730289802OtherPHYSICIAN
MS1073679817OtherNURSE PRACTITIONER
MS1801997127OtherPHYSICIAN
MS1316016066OtherPHYSICIAN
MS0119422Medicaid
MS1235270885OtherCOPAC INCORPORATED
MS1100010449Medicare ID - Type Unspecified
MS0119422Medicaid