Provider Demographics
NPI:1134827728
Name:COPHER, JAYCEE AMANDA
Entity type:Individual
Prefix:
First Name:JAYCEE
Middle Name:AMANDA
Last Name:COPHER
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 1:365 WARNER MILNE RD STE 110
Mailing Address - Street 2:
Mailing Address - City:OREGON CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97045-4073
Mailing Address - Country:US
Mailing Address - Phone:971-206-7115
Mailing Address - Fax:
Practice Address - Street 1:365 WARNER MILNE RD
Practice Address - Street 2:
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-4073
Practice Address - Country:US
Practice Address - Phone:971-206-7115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-22
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD0003125J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes125J00000XDental ProvidersDental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORDT0003Medicaid