Provider Demographics
NPI:1134865272
Name:COOPER, JILLIAN (RDH)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:
Last Name:COOPER
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 NORH 6 MILE LANE
Mailing Address - Street 2:
Mailing Address - City:FORT GIBSON
Mailing Address - State:OK
Mailing Address - Zip Code:74434
Mailing Address - Country:US
Mailing Address - Phone:918-869-0089
Mailing Address - Fax:
Practice Address - Street 1:801 S LEE ST STE A
Practice Address - Street 2:
Practice Address - City:FORT GIBSON
Practice Address - State:OK
Practice Address - Zip Code:74434-8710
Practice Address - Country:US
Practice Address - Phone:918-478-4433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-11
Last Update Date:2022-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3257124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist