Provider Demographics
NPI:1639107469
Name:COOPER, JON (PT)
Entity type:Individual
Prefix:
First Name:JON
Middle Name:
Last Name:COOPER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:139 FOX RD
Mailing Address - Street 2:SUITE 111
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37922-3472
Mailing Address - Country:US
Mailing Address - Phone:865-539-2606
Mailing Address - Fax:865-539-2446
Practice Address - Street 1:139 FOX RD
Practice Address - Street 2:SUITE 111
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37922-3472
Practice Address - Country:US
Practice Address - Phone:865-539-2606
Practice Address - Fax:865-539-2446
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPT6034225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3659122Medicaid
TN4082601OtherBCBS
TN3659122Medicare ID - Type UnspecifiedPROVIDER NUMBER