Provider Demographics
NPI:1801250287
Name:COOPER, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:COOPER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 OLD DAWSON VILLAGE RD E
Mailing Address - Street 2:SUITE 020
Mailing Address - City:DAWSONVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30534-3806
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1100 OLD DAWSON VILLAGE RD E
Practice Address - Street 2:SUITE 020
Practice Address - City:DAWSONVILLE
Practice Address - State:GA
Practice Address - Zip Code:30534-3806
Practice Address - Country:US
Practice Address - Phone:678-914-4334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-11
Last Update Date:2016-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC005350101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor