Provider Demographics
NPI:1780136945
Name:COOPERATIVE THERAPY LLC
Entity type:Organization
Organization Name:COOPERATIVE THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOBSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LCSW
Authorized Official - Phone:314-914-5762
Mailing Address - Street 1:412 S CLAY AVE
Mailing Address - Street 2:LOWER LEVEL
Mailing Address - City:KIRKWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63122-5860
Mailing Address - Country:US
Mailing Address - Phone:314-914-5762
Mailing Address - Fax:
Practice Address - Street 1:412 S CLAY AVE
Practice Address - Street 2:LOWER LEVEL
Practice Address - City:KIRKWOOD
Practice Address - State:MO
Practice Address - Zip Code:63122-5860
Practice Address - Country:US
Practice Address - Phone:314-914-5762
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-03
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20070316201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty