Provider Demographics
NPI:1205104379
Name:COPELAND, JENNIFER ELIZABETH (PSYD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ELIZABETH
Last Name:COPELAND
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2526
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64803-2526
Mailing Address - Country:US
Mailing Address - Phone:417-358-7728
Mailing Address - Fax:417-347-0293
Practice Address - Street 1:3901 E 32ND ST
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-3312
Practice Address - Country:US
Practice Address - Phone:417-347-7567
Practice Address - Fax:417-347-0293
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-05
Last Update Date:2018-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012033727103TC0700X
2012033727103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS201087620AMedicaid
MO1205104379Medicaid