Provider Demographics
NPI:1255948519
Name:COPPEDGE, JAAFAH RASHAD (BA)
Entity type:Individual
Prefix:
First Name:JAAFAH
Middle Name:RASHAD
Last Name:COPPEDGE
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:JAY
Other - Middle Name:RASHAD
Other - Last Name:COPPEDGE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:BA
Mailing Address - Street 1:4400 S JONES BLVD UNIT 1028
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89103-3337
Mailing Address - Country:US
Mailing Address - Phone:702-481-8806
Mailing Address - Fax:
Practice Address - Street 1:4400 S JONES BLVD UNIT 1028
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89103-3337
Practice Address - Country:US
Practice Address - Phone:702-481-8806
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-30
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior AnalystGroup - Single Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No167G00000XNursing Service ProvidersLicensed Psychiatric Technician
No175T00000XOther Service ProvidersPeer Specialist
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)