Provider Demographics
NPI:1023742681
Name:COOPER, JACQUELINE (RN)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:COOPER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 COUNTY ROAD 331
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:MS
Mailing Address - Zip Code:38851-7006
Mailing Address - Country:US
Mailing Address - Phone:662-542-9440
Mailing Address - Fax:
Practice Address - Street 1:212 LOT1 COUNTY RD 331
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:MS
Practice Address - Zip Code:38851
Practice Address - Country:US
Practice Address - Phone:662-542-9440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-11
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS895548163WH0200X, 374U00000X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WH0200XNursing Service ProvidersRegistered NurseHome Health
No374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS863785168OtherMEDICARE
MS863785168Medicaid