Provider Demographics
NPI:1205327707
Name:COOPER, JACKIE
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:
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 1:12511 JONES MALTSBERGER RD APT 2205
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78247-4286
Mailing Address - Country:US
Mailing Address - Phone:210-833-7163
Mailing Address - Fax:210-855-7471
Practice Address - Street 1:12511 JONES MALTSBERGER RD APT 2205
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78247-4286
Practice Address - Country:US
Practice Address - Phone:210-833-7163
Practice Address - Fax:210-855-7471
Is Sole Proprietor?:No
Enumeration Date:2018-05-21
Last Update Date:2018-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator