Provider Demographics
NPI:1780141630
Name:COPPAGE, JEROME ANTHONY JR (BCBA 1-21-55996)
Entity type:Individual
Prefix:
First Name:JEROME
Middle Name:ANTHONY
Last Name:COPPAGE
Suffix:JR
Gender:M
Credentials:BCBA 1-21-55996
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30073 VIA AMANTE
Mailing Address - Street 2:
Mailing Address - City:MENIFEE
Mailing Address - State:CA
Mailing Address - Zip Code:92584-8910
Mailing Address - Country:US
Mailing Address - Phone:619-895-4615
Mailing Address - Fax:
Practice Address - Street 1:30073 VIA AMANTE
Practice Address - Street 2:
Practice Address - City:MENIFEE
Practice Address - State:CA
Practice Address - Zip Code:92584-8910
Practice Address - Country:US
Practice Address - Phone:619-895-4615
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-27
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-16-4282-36534106S00000X
106S00000X
CA1-21-55996103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician