Provider Demographics
NPI:1245693746
Name:COOPER, JENNIFER (APRN)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:COOPER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5516 CREPE MYRTLE RD
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:SC
Mailing Address - Zip Code:29745-9674
Mailing Address - Country:US
Mailing Address - Phone:803-517-8774
Mailing Address - Fax:
Practice Address - Street 1:222 S HERLONG AVE
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-1158
Practice Address - Country:US
Practice Address - Phone:803-329-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-01
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20116363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner