Provider Demographics
NPI:1770117970
Name:COOPER, JACOB
Entity type:Individual
Prefix:MR
First Name:JACOB
Middle Name:
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 1:848 EXECUTIVE DR
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-7699
Mailing Address - Country:US
Mailing Address - Phone:863-414-1111
Mailing Address - Fax:
Practice Address - Street 1:848 EXECUTIVE DR
Practice Address - Street 2:
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765-7699
Practice Address - Country:US
Practice Address - Phone:407-678-8889
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-26
Last Update Date:2020-09-03
Deactivation Date:2020-08-12
Deactivation Code:
Reactivation Date:2020-08-21
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician