Provider Demographics
NPI:1942069026
Name:COOPER, JESSICA PHILLIS
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:PHILLIS
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 1:1017 SAMSON DR
Mailing Address - Street 2:
Mailing Address - City:UNIVERSITY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60484-3226
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14933 FOUNDERS XING
Practice Address - Street 2:
Practice Address - City:HOMER GLEN
Practice Address - State:IL
Practice Address - Zip Code:60491-6712
Practice Address - Country:US
Practice Address - Phone:170-873-7796
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-19
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178020007101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health