Provider Demographics
NPI:1750921110
Name:COOPER, JASON TYRONE
Entity type:Individual
Prefix:MR
First Name:JASON
Middle Name:TYRONE
Last Name:COOPER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3628 MADISON AVE STE 7
Mailing Address - Street 2:
Mailing Address - City:NORTH HIGHLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:95660-5070
Mailing Address - Country:US
Mailing Address - Phone:916-567-4222
Mailing Address - Fax:
Practice Address - Street 1:3628 MADISON AVE STE 7
Practice Address - Street 2:
Practice Address - City:NORTH HIGHLANDS
Practice Address - State:CA
Practice Address - Zip Code:95660-5070
Practice Address - Country:US
Practice Address - Phone:916-840-1413
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-13
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 171M00000X
CA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator